CMG Reckoning

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Pudortu

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So lately I've heard a lot of bad news from multiple sources about how CMG's are hurting financially.
I've been hearing about how the No Surprises act has really cut down on pay that CMGs used to receive due to the reconciliation process. I've heard numbers quoted around a 25% payout from the commercial insurance side. I see other threads and hear personally from colleagues about Team Health taking a beating, Envision and USACS in all this debt, APP in crazy debt deals, and Schumacher hurting badly also. Hell, even my friend in a SDG in town is leaving (to join a CMG ironically) because pay is getting cut so badly.

How does this play out for us lowly docs? We all have our feelings toward CMGs, but if they don't get paid I don't see how they can afford to pay us now. Does our pay get cut nationally as a whole? The current job market is super duper in our favor, and I figured CMGs would wait a couple years and hold out to have that flip (ie ACEP job report)...but I don't see them holding on that long with how bad things are getting and all the grumbles I've heard. Interest rates are going up fast and I feel like they relied on super cheap debt.

Sorry I know this seems like a "sky is falling" post but I see the writing on the wall and want to prepare for it. Are you all hearing anything like this? What's the best way to prep? Do you see us all getting a big pay cut nationally?

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I personally spoke with the CEO of Schumacher, Rich D’Amaro at their Atlanta head office.

SCP isn’t thriving, but still managed to turn profits and their debt situation is very manageable. Low interest $500 million loan with a long payback period and annual revenue of $200 mil. They have let a lot of admin go and cut admin costs from 15% to 7.5% of operating budget. They even formed an advisory committee full of their docs and midlevels, flew us out to Atlanta and fed us, put up in hotels for a meeting.

But overall yes agree with everything, picture looks grim.
 
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No Suprises Billing Act started as as well intentioned legislation to protect patients from predatory practices by CMGs and hospitals and ended up as a boondoggle for insurance companies. Many are using it as a chance to immediately go out of network rather than negotiate reasonable rates and then use the backed up arbitration system required by the legislation to settle on a new (much lower) reimbursement scale. As a result everyone is going to be hurting to some degree, even those who weren’t doing balanced billing before as insurance providers aren’t negotiating in good faith.

We just had one of the major national insurance companies come back to us with a 30% cut for 2023. We either take it, or get paid their offer while sitting in a line for arbitration that could take 6-18 months to work through. And what do you pay the docs while waiting on that ruling? Do you assume you win and take out debt (at new high interest rates) or cut pay and see what happens. Add in CMS cuts which seem to be delayed every year but threaten 6-7% cut this year unless congress kicks the can down the road again and things are looking bleak.

Best case scenario we work even harder, spend less time with patients and pump up efficiency 7-10% again next year or else face a pay cut. Not what you need in the face of 8-10% inflation and morale hammer coming out of a pandemic.

Everyone is facing these headwinds now. Not just CMGs.
 
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Agreed. So much negativity in front of us.

The issue is insurers will drop you in a heartbeat but most groups are too scared to go out of network with insurers. Still ptsd from before.

Insurers own all the data to make a decision whereas the doc groups have to consider a calculated risk.

I’m theory everyone will be out of network or being paid less than what the law mandates by the qpa.

In a southwestern state envision is dropping all contracts with less than a 10% profit margin.

Envision is pissing off their debt holders. They have 12-18 months before something major happens. Many expect them to be bought by sound physicians.

Similarly hca is getting pissed at envision and they are likely to dissolve their joint venture.

Also the cms cuts are scheduled to be 9%.

The Texas medical association lawsuit is the only hope for EM. The current interpretation of the law will hammer everyone.

It’s funny how people point to the tough situation for sdgs. If you believe the well accepted mantra of cmgs have better contracts then by rule they will be hammered harder.

Sdgs need to be smart and aggressive going out of network. Can’t accept the status quo.
 
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Agreed. So much negativity in front of us.

The issue is insurers will drop you in a heartbeat but most groups are too scared to go out of network with insurers. Still ptsd from before.

Insurers own all the data to make a decision whereas the doc groups have to consider a calculated risk.

I’m theory everyone will be out of network or being paid less than what the law mandates by the qpa.

In a southwestern state envision is dropping all contracts with less than a 10% profit margin.

Envision is pissing off their debt holders. They have 12-18 months before something major happens. Many expect them to be bought by sound physicians.

Similarly hca is getting pissed at envision and they are likely to dissolve their joint venture.

Also the cms cuts are scheduled to be 9%.

The Texas medical association lawsuit is the only hope for EM. The current interpretation of the law will hammer everyone.

It’s funny how people point to the tough situation for sdgs. If you believe the well accepted mantra of cmgs have better contracts then by rule they will be hammered harder.

Sdgs need to be smart and aggressive going out of network. Can’t accept the status quo.
Can you elaborate on the TMA lawsuit and what it means for EM going forward?
 
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Envision is pissing off their debt holders. They have 12-18 months before something major happens. Many expect them to be bought by sound physicians.
Sound is a much smaller group than Envision. They really have the capital to buy them out?
 
I think they are owned by UnitedHealth/Optum Health so they have lots of insurance money
 
An insurance company owning ed contracts?

Jesus, I thought private equity was bad.

What do they staff with? A med student with free uptodate access?

"Once you get in-network....you can never get out"
 
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An insurance company owning ed contracts?

Jesus, I thought private equity was bad.

What do they staff with? A med student with free uptodate access?

"Once you get in-network....you can never get out"
Nah, Med student would order too many tests and admit everyone. They’d find the most grizzled of the grizzly old EP’s. The ones that send 68 y/o’s with 15 minutes of subssternal chest pain while walking up stairs 30 minutes ago home after 1 negative troponin. You know, the ones that play EP Russian roulette on a daily basis- every group has one.
 
I personally spoke with the CEO of Schumacher, Rich D’Amaro at their Atlanta head office.

SCP isn’t thriving, but still managed to turn profits and their debt situation is very manageable. Low interest $500 million loan with a long payback period and annual revenue of $200 mil. They have let a lot of admin go and cut admin costs from 15% to 7.5% of operating budget. They even formed an advisory committee full of their docs and midlevels, flew us out to Atlanta and fed us, put up in hotels for a meeting.

But overall yes agree with everything, picture looks grim.
That's so cool, my guy. Did you get his autograph?
 
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Can you elaborate on the TMA lawsuit and what it means for EM going forward?
Well simply they are suing the govt about how they set the rules for the arbitration process for out of network bills. The Biden administration st it in a way that is highly slanted toward insurers. They essentially rate et via the QPA. the Texas suit won an initial suit and then new rules were set but basically no real change from before so they continued their suit.
 
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Sound is a much smaller group than Envision. They really have the capital to buy them out?
As I think mentioned, sound is owned by Optum, optum emplys 6% (1 of 16) of all docs in the US, Optum is owned by united Healthcare which is the 5th largest corporation in America.
 
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As I think mentioned, sound is owned by Optum, optum emplys 6% (1 of 16) of all docs in the US, Optum is owned by united Healthcare which is the 5th largest corporation in America.
In a weird American corporate view of things, it seems like that is the end stage of the current system as-is. We just work for insurance companies and bypass the middleman of staffing groups and hospitals. Not saying it’s good or bad, (guess is probably bad at worst, ok at best).
 
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In a weird American corporate view of things, it seems like that is the end stage of the current system as-is. We just work for insurance companies and bypass the middleman of staffing groups and hospitals. Not saying it’s good or bad, (guess is probably bad at worst, ok at best).
De facto this is already happening but not just to em docs. All docs do what the insurers say. All the guidelines and mips macra “quality” is all insurance and cms nonsense. Very little is actually thought through.

I can’t see how the current system can continue but I also appreciate that those 10-20 years older than me said the same. I am lucky I focused on aggressive savings early on and made good money while it was there. Unless congress acts cms is about to drop a 10% cut on docs and that doesn’t even account for insane inflation.

If a group/cmg was dumb enough to sign a commercial contract tied to variable cms rates they are gonna see major pain.

Not hard to believe between this, the nsa and inflation em docs will make 25% less in real money next year compared to this year.

Hard not to see pay cuts as inflation roars and interest rates rise that cmgs are going to beg for mercy.
 
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De facto this is already happening but not just to em docs. All docs do what the insurers say. All the guidelines and mips macra “quality” is all insurance and cms nonsense. Very little is actually thought through.

When ever I talk about sepsis treatment I always include the disclaimer that we have to follow the golden rule.

He who has the gold (CMS) makes the rules.
 
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It appears Moody’s downgraded Teamhealth and Envision to Caa3.
Basically it means their bonds and loans are junk.
It also means Moody’s thinks they will bankrupt soon.
 
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It appears Moody’s downgraded Teamhealth and Envision to Caa3.
Basically it means their bonds and loans are junk.
It also means Moody’s thinks they will bankrupt soon.

I'm not greatly knowledgeable about this part of things. I thought I keep hearing about TH with their "record profits," how does this swing so quickly to possible bankrupty? Unless this is somehow tied to new reimbursement issues coming up?
 
I'm not greatly knowledgeable about this part of things. I thought I keep hearing about TH with their "record profits," how does this swing so quickly to possible bankrupty? Unless this is somehow tied to new reimbursement issues coming up?
Who says TH has record profits?
 
Meh.

Maybe I just misheard or misunderstood. Then maybe there aren't and then the situation would make more sense.
 
It appears Moody’s downgraded Teamhealth and Envision to Caa3.
Basically it means their bonds and loans are junk.
It also means Moody’s thinks they will bankrupt soon.

I would support nationwide strike pay that all ER docs support so docs don't get screwed out of negotiations with CMGs. It would be funded by ER docs.
Wait...this is called a union. 😮

There are about 30,000 practicing BC ER MDs and DOs right now. More or less. Each pays $50/month into a strike fund. Each year the fund collects (30,000 * 50 * 12) = $18M. Distribute weekly payments of $2000 to each doc in a group that sits out and doens't staff an ER due to CMG contract negotiation shenanigans. So a typical group of 25 ER docs that strikes for 1 week would get $50,000/week from the strike fund.
 
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I would support nationwide strike pay that all ER docs support so docs don't get screwed out of negotiations with CMGs. It would be funded by ER docs.
Wait...this is called a union. 😮

There are about 30,000 practicing BC ER MDs and DOs right now. More or less. Each pays $50/month into a strike fund. Each year the fund collects (30,000 * 50 * 12) = $18M. Distribute weekly payments of $2000 to each doc in a group that sits out and doens't staff an ER due to CMG contract negotiation shenanigans. So a typical group of 25 ER docs that strikes for 1 week would get $50,000/week from the strike fund.
I'm sure there is a federal law that prevents that.
 
I'm sure there is a federal law that prevents that.

Yea I was looking it up...something about how it violates antitrust law. But I think it's certain classes of doctors, like independent contractor doctors. I dunno.

This link suggests that if you are an employee you have a right to organize into a union for collective bargaining purposes. However most if not all ER docs are not in this class of employees.
 
I'm not greatly knowledgeable about this part of things. I thought I keep hearing about TH with their "record profits," how does this swing so quickly to possible bankrupty? Unless this is somehow tied to new reimbursement issues coming up?
According to Moody’s Teamhealth made $100-125 million in free cash flow this year. It has a $300 million dollar loan due in 1 year, which won’t be renewed due to their junk bond status.
$464 million loan also due next year
$1.2 Billion due in 2027.

Basically Moody’s is saying they will not be able to pay their debt as they don’t make enough money. Or they will have to get another private equity overlord to stay afloat
 
Now, is this a second and subsequent rating change after the one that was already discussed early in the threa
 
Now, is this a second and subsequent rating change after the one that was already discussed early in the threa
As of October 22 2022. It’s downgraded again since the previous downgrade
 
According to Moody’s Teamhealth made $100-125 million in free cash flow this year. It has a $300 million dollar loan due in 1 year, which won’t be renewed due to their junk bond status.
$464 million loan also due next year
$1.2 Billion due in 2027.

Basically Moody’s is saying they will not be able to pay their debt as they don’t make enough money. Or they will have to get another private equity overlord to stay afloat
PE is king of gaming the system. I'm quite sure they have this all figured out. They probably will file for bankruptcy and another company will somehow emerge that will miraculously secure the previous TeamHealth contracts. I find it hard to believe Blackstone Group would not have this all planned out in a way that benefits them.
 
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According to Moody’s Teamhealth made $100-125 million in free cash flow this year. It has a $300 million dollar loan due in 1 year, which won’t be renewed due to their junk bond status.
$464 million loan also due next year
$1.2 Billion due in 2027.

Basically Moody’s is saying they will not be able to pay their debt as they don’t make enough money. Or they will have to get another private equity overlord to stay afloat
Link? To article?
 
According to Moody’s Teamhealth made $100-125 million in free cash flow this year. It has a $300 million dollar loan due in 1 year, which won’t be renewed due to their junk bond status.
$464 million loan also due next year
$1.2 Billion due in 2027.

Basically Moody’s is saying they will not be able to pay their debt as they don’t make enough money. Or they will have to get another private equity overlord to stay afloat

So funny. Why does TeamHealth have all that debt? Being a CMG doesn’t appear to be a capital intensive business, in the grand scheme of things.
 
So funny. Why does TeamHealth have all that debt? Being a CMG doesn’t appear to be a capital intensive business, in the grand scheme of things.
When you are spending near $35 million a year, just for executive salaries.
 
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So funny. Why does TeamHealth have all that debt? Being a CMG doesn’t appear to be a capital intensive business, in the grand scheme of things.
You're kidding, right? Ignoring the boat load of debt that comes each time PE takes over, the actual business of being an expanding CMG fighting for market share is extraordinarily capital intensive. There are SDGs that need to be bought out, sign on bonuses paid, and the ability to float 0 income for 6 months while billing comes on line. They leveraged steady profit for explosive growth, and when profit dips when your debt's due that's a really bad look.
 
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An insurance company owning ed contracts?

Jesus, I thought private equity was bad.

What do they staff with? A med student with free uptodate access?

"Once you get in-network....you can never get out"

Actually my wife is employed by Optum aka united health. Maybe family medicine is a really hot commodity, but they go wayyyy out of the way to make sure their doctors are happy and getting what they need.

Having said that, optum had recently bought out a private group, and some of the work culture likely spilled over from that private group. But essentially, she’s gotten an extra week of vacation than her contract, she’s never given any push back on leaving early if there’s no one scheduled- she just tells them not to put any one on her schedule. She’s taken several last minute days off or had to leave the office - like Day care issues with them sending the kid home. She’s never had an issue with that, and they are extremely accommodating always and do whatever she asks, sometimes they do more than what she’s asking. The CEO of optum has come to their clinic twice just to talk to doctors and get their opinion on what they need or what they can do to support them more. And even after a year, she’s only averaging 10 patients a day, she’s never been pushed to see more patients. In fact, even when hiring, they were encouraging her to be part time with young children. And they literally just paid more for a lot of things than they didn’t need to - she turned in CME things, the meal limit was $50/meal. The receipts that were sent were sometimes more. We totally expected them to stick to their limits, but no, they paid everything without question. Similarly, if she ever needs a new stethoscope or something, they won’t tell her to use CME funds, they just get her one. And not to mention the lunch they feed her in clinic, almost once a week their admin buys them lunch. And it’s not pizza - fancy catered stuff. Fancier than what drug reps bring 😅

So far optum is a great employer. We’ve been very impressed.
 
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Actually my wife is employed by Optum aka united health. Maybe family medicine is a really hot commodity, but they go wayyyy out of the way to make sure their doctors are happy and getting what they need.

Having said that, optum had recently bought out a private group, and some of the work culture likely spilled over from that private group. But essentially, she’s gotten an extra week of vacation than her contract, she’s never given any push back on leaving early if there’s no one scheduled- she just tells them not to put any one on her schedule. She’s taken several last minute days off or had to leave the office - like Day care issues with them sending the kid home. She’s never had an issue with that, and they are extremely accommodating always and do whatever she asks, sometimes they do more than what she’s asking. The CEO of optum has come to their clinic twice just to talk to doctors and get their opinion on what they need or what they can do to support them more. And even after a year, she’s only averaging 10 patients a day, she’s never been pushed to see more patients. In fact, even when hiring, they were encouraging her to be part time with young children. And they literally just paid more for a lot of things than they didn’t need to - she turned in CME things, the meal limit was $50/meal. The receipts that were sent were sometimes more. We totally expected them to stick to their limits, but no, they paid everything without question. Similarly, if she ever needs a new stethoscope or something, they won’t tell her to use CME funds, they just get her one. And not to mention the lunch they feed her in clinic, almost once a week their admin buys them lunch. And it’s not pizza - fancy catered stuff. Fancier than what drug reps bring 😅

So far optum is a great employer. We’ve been very impressed.
Interesting. On the other hand, I can tell you from personal experience that Sound, the CMG wing of Optum used for EM, Gas and Hospital Medicine, appears to go wayyyy out of their way to make docs unhappy and burn them out.
 
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Interesting. On the other hand, I can tell you from personal experience that Sound, the CMG wing of Optum used for EM, Gas and Hospital Medicine, appears to go wayyyy out of their way to make docs unhappy and burn them out.

Great just signed on as a per diem with Sound. Guess worst case I just dont work.
 
Actually my wife is employed by Optum aka united health. Maybe family medicine is a really hot commodity, but they go wayyyy out of the way to make sure their doctors are happy and getting what they need.

Having said that, optum had recently bought out a private group, and some of the work culture likely spilled over from that private group. But essentially, she’s gotten an extra week of vacation than her contract, she’s never given any push back on leaving early if there’s no one scheduled- she just tells them not to put any one on her schedule. She’s taken several last minute days off or had to leave the office - like Day care issues with them sending the kid home. She’s never had an issue with that, and they are extremely accommodating always and do whatever she asks, sometimes they do more than what she’s asking. The CEO of optum has come to their clinic twice just to talk to doctors and get their opinion on what they need or what they can do to support them more. And even after a year, she’s only averaging 10 patients a day, she’s never been pushed to see more patients. In fact, even when hiring, they were encouraging her to be part time with young children. And they literally just paid more for a lot of things than they didn’t need to - she turned in CME things, the meal limit was $50/meal. The receipts that were sent were sometimes more. We totally expected them to stick to their limits, but no, they paid everything without question. Similarly, if she ever needs a new stethoscope or something, they won’t tell her to use CME funds, they just get her one. And not to mention the lunch they feed her in clinic, almost once a week their admin buys them lunch. And it’s not pizza - fancy catered stuff. Fancier than what drug reps bring 😅

So far optum is a great employer. We’ve been very impressed.
How is her actual pay, you did not mention that.

I had an Optum group offer but they more or less paid below MGMA median but you could maybe the median if you busted your butt after a few years. Then again maybe they were using that money to make their PCPs happier.
 
Great just signed on as a per diem with Sound. Guess worst case I just dont work.
Per diem not so bad, as you can set your own schedule and ignore any emails from the med director. If this is for ICU, get ready to be shocked and horrified by the midlevels running the unit. Wouldn't get dependent on shifts w/ them, they'll lie to your face regarding their needs and hiring plans.
 
I don't think Envision and USACS are any better.
They aren’t. All of them have massive debts and decreased reimbursements.

We will likely see them do the following options:
1) more private equity partners
2) go public with an IPO
3) rebrand to a new company after bankruptcy
4) break up into smaller groups
 
How is her actual pay, you did not mention that.

I had an Optum group offer but they more or less paid below MGMA median but you could maybe the median if you busted your butt after a few years. Then again maybe they were using that money to make their PCPs happier.

Median for family medicine. 230k plus 25k sign on bonus plus 25k retention bonus over the next 3 years. 36 weekly hours, which is probably more like 33 ish hours since often the last slot won’t have a scheduled patient. Full rvu based after 2 years guaranteed. RVU model honestly comes down to patient panel size and especially how many Medicare advantage patients a person has on their panel. The bonuses for large panel size really move the income. Otherwise the per rvu dollar Is pretty standard. I believe if she does 4800 rvu annually then she’s at 275 plus bonuses for quality measures and patient panel. If you meet all measures and have a 3000 plus panel, i think you end up around 320-340k.

Also they were very open to negotiating the non compete which almost every family practice has. Brought down the mileage to 10 miles and 6 months. They showed a lot more wiggle room than some other groups locally here.

They have also been very accommodating to schedule. She’s literally the only person whose clinic starts at 7:30 because she wanted to be done at 3 pm and beat rush hour. We’ve changed schedule a couple of times to figure out what works best for our family, no issue at all. And I’m sure when she goes part time, it won’t be an issue either.

Edit: to give you context, she’s 1 year in and generating 230-260 monthly RVUs and currently getting 230k per year as her fixed base. For the patient volume, it’s a great gig.
 
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Otherwise the per rvu dollar Is pretty standard. I believe if she does 4800 rvu annually then she’s at 275 plus bonuses for quality measures and patient panel.

Is that wrvu target average for family medicine? That seems crazy low but maybe my numbers in EM aren't an appropriate comparison.
 
Is that wrvu target average for family medicine? That seems crazy low but maybe my numbers in EM aren't an appropriate comparison.

Yes that’s actually average for family medicine.

EM makes more and generates more rvus.
 
Yes that’s actually average for family medicine.

EM makes more and generates more rvus.
She's actually getting paid very well by FM standards for her volume. For example, with those yearly RVU numbers at my current job before bonuses I'd be making right at 200k.

That's not a surprise, with insurance-operated clinics quality is the name of the game and how they make most of their money.
 
Yes that’s actually average for family medicine.

EM makes more and generates more rvus.

She's actually getting paid very well by FM standards for her volume. For example, with those yearly RVU numbers at my current job before bonuses I'd be making right at 200k.

That's not a surprise, with insurance-operated clinics quality is the name of the game and how they make most of their money.

VA addressed exactly what I was getting at. The fact that she has a lower salary and a lower rvu generation than me is not shocking. The fact that she's somehow getting paid 275k + bonuses (and presumably benefits, unless this is 1099 income) for 4800 wRVUs is what shocked me. That means she's making well in excess of $57/RVU which is crazy high. Especially in FM where it isn't like your employer is making bank on the non wRVU generation for facility fees and whatnot and can afford to kick you some extra (a la pain med, ortho, etc)
 
VA addressed exactly what I was getting at. The fact that she has a lower salary and a lower rvu generation than me is not shocking. The fact that she's somehow getting paid 275k + bonuses (and presumably benefits, unless this is 1099 income) for 4800 wRVUs is what shocked me. That means she's making well in excess of $57/RVU which is crazy high. Especially in FM where it isn't like your employer is making bank on the non wRVU generation for facility fees and whatnot and can afford to kick you some extra (a la pain med, ortho, etc)

Well she’s currently just at 230k guaranteed. The 275k is if she sees that many Rvus, the rvu number may be 5200 and not 4800, im a little hazy on the exact details since it’s been a year and a half since i reviewed her contract. We will see how it goes once she is Rvu only. But seeing how she probably generated around 3000 rvus in her first year as attending, getting 230k w2 plus 25k for that first year was a win for us 😅 not to mention 5 weeks off, 4.5k cme, stock option in United healthcare stock at a 10 percent discount, 401k match. It’s really not a bad option.

But all in all, we have been extremely satisfied with optum as an employer. They actually get a huge kickback from Medicare advantage patients. So maybe that’s how they give their docs a little extra?

Though this is midwest - even the university system that we were almost ready to sign up for had excellent compensation, but no willingness to negotiate though. With a 4000 patient panel, i think the university gave a bonus of 40,000 itself. And a good number of their FM docs made 300k+

Either way, I’m hazy on the details. But the income is decent. She’s very happy. The admin is extremely supportive. It’s been a good experience so far
 
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Well she’s currently just at 230k guaranteed. The 275k is if she sees that many Rvus, the rvu number may be 5200 and not 4800, im a little hazy on the exact details since it’s been a year and a half since i reviewed her contract. We will see how it goes once she is Rvu only. But seeing how she probably generated around 3000 rvus in her first year as attending, getting 230k w2 plus 25k for that first year was a win for us 😅 not to mention 5 weeks off, 4.5k cme, stock option in United healthcare stock at a 10 percent discount, 401k match. It’s really not a bad option.

But all in all, we have been extremely satisfied with optum as an employer. They actually get a huge kickback from Medicare advantage patients. So maybe that’s how they give their docs a little extra?

Though this is midwest - even the university system that we were almost ready to sign up for had excellent compensation, but no willingness to negotiate though. With a 4000 patient panel, i think the university gave a bonus of 40,000 itself. And a good number of their FM docs made 300k+

Either way, I’m hazy on the details. But the income is decent. She’s very happy. The admin is extremely supportive. It’s been a good experience so far
That's exactly how. We're getting a decent raise next year because of quality measures through MA plans.

That said, the Feds are taking notice of this: ‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions
 
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