CMG Reckoning

[3rdJob]

"Outlook stable" like a CPR in progress on a patient with rigor mortis.

Good Lord, those ratings are awful....:O

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[Arcan57]

Good Lord, those ratings are awful....:O

Maybe their CEO's pay should be based off the company's rating as a percentile compared to a select group of companies with wildly different demographics.

 

[minor.groove]

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

what happens when one of these big CMG explodes? Has there been an example?

 

[sylvanthus]

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.

Naww its for ER, they are so short staffed atm. Apprently the hospital fired the whole ED team due to some drama after a doc molested ED patients. Reminds me of the facial dude who was all about the patient doc relationship. What was that dudes name? Apparently was well respected back in the day.

 

[RustedFox]

Naww its for ER, they are so short staffed atm. Apprently the hospital fired the whole ED team due to some drama after a doc molested ED patients. Reminds me of the facial dude who was all about the patient doc relationship. What was that dudes name? Apparently was well respected back in the day.

- and why should the whole department bear such a punishment for the actions of one doc?

I mean, if there were a good reason (cover-up, whatever), I get it - but we know how admins throw tantrums.

 

[BoardingDoc]

Reminds me of the facial dude who was all about the patient doc relationship. What was that dudes name? Apparently was well respected back in the day.

I'm assuming you're referencing David Newman at Mt. Sinai in NYC.

And I'm with @RustedFox on this one. Why was the entire department fired? That makes no sense unless the perception was that those other docs were somehow also involved.

 

[xaelia]

I'm assuming you're referencing David Newman at Mt. Sinai in NYC.

He's out of prison, btw.

 

[turkeyjerky]

He's out of prison, btw.

Eckman? I thought he was doing time?

No, no, he's out. He got out.

 

[alpinism]

News Link: Olympic Medical Center to change Emergency Department firm | Peninsula Daily News

 

[turkeyjerky]

News Link: Olympic Medical Center to change Emergency Department firm | Peninsula Daily News

Okay, that makes a lot more sense. Hospital gets an excuse to dump local group for CMG.

Sound is relatively small compared to the bigger CMGs like team, envision, et al. Despite this, they have an absolutely dismal reputation which is well known and well deserved. Yet, they seem to be rapidly expanding. For anyone who thinks that the coming financial reckoning will somehow lead to a rebirth of our speciality--it won't. Meet the new boss, worse than the old boss.

 

[sylvanthus]

- and why should the whole department bear such a punishment for the actions of one doc?

I mean, if there were a good reason (cover-up, whatever), I get it - but we know how admins throw tantrums.

No idea, maybe it was all about money and sound offered a lower cost for the hospital and the sexual assault was just smoke and mirrors or only a part of it. /shrug

 

[Arcan57]

what happens when one of these big CMG explodes? Has there been an example?

AFAIK, no major PE backed CMG has suffered catastrophic failure. They've danced on the edge but the funding has always been there in the past. My expectation would be that they don't explode so much as crumble apart. They'll start shedding low performing contracts, with/without loading those contracts onto a subsidiary that can be sacrificed. Contracts with big hospital chains that are sufficiently recruited will likely have the hospital assume the contract and keep the money flowing in order to keep the docs in place. Large systems that still need to recruit will get gobbled up by whichever PE backed CMG is most solvent at the time. Again, docs will keep getting paid to avoid having to recruit an entirely new staff. There's more likelihood of turbulence in small hospital groups, especially if they need to recruit. These will go to 2nd tier CMGs in the name of showing growth in contracts (if not profits) to the investors or hospital may try and make a run of it with current staff + locums. Poor or critical access hospitals will try and cobble something together but many of them are barely solvent as is and can't float 6 months of ED salary just to keep a group of what are ultimately cogs happy.

 

[bravotwozero]

The PE backed CMGs are about to lose their PE backing this time around, as PE realizes they’re no longer profitable and they won’t get their money back. That’s the difference.

 

[EctopicFetus]

The PE backed CMGs are about to lose their PE backing this time around, as PE realizes they’re no longer profitable and they won’t get their money back. That’s the difference.

Agreed. i think this time its a different story. PE is gonna bail and they wont crumble. they are ruthless business people they cut bait quick and with no notice.

 

[RustedFox]

Agreed. i think this time its a different story. PE is gonna bail and they wont crumble. they are ruthless business people they cut bait quick and with no notice.

So let's say that PE bails... Poof. No more Envision/TeamHealth.

What happens then; within realistic probability - ?

 

[Restart13]

So let's say that PE bails... Poof. No more Envision/TeamHealth.

What happens then; within realistic probability - ?

I would love to see functioning fair SDGs return to once barren cities. I think hospital admin is aware of the toxicity of CMGs and would be willing to work with a reliable HAPPY group of docs in the form of an SDG. not to say some hospitals won’t mind bringing them on payroll either.

 

[RustedFox]

I would love to see functioning fair SDGs return to once barren cities. I think hospital admin is aware of the toxicity of CMGs and would be willing to work with a reliable HAPPY group of docs in the form of an SDG. not to say some hospitals won’t mind bringing them on payroll either.

Yeah, me too - but that's not the question that I asked.

 

[Restart13]

Yeah, me too - but that's not the question that I asked.

I think it’s more realistic if the titan CMGs are gone and out of the picture. You can always have team health 2.0/more PE come in as well. I think maybe more realistic is hospital employment as well.

 

[bravotwozero]

1 - hospital employment.
2 - University/academic employment, as they have resources
3 - insurance companies

PE might sit this one out.

 

[EctopicFetus]

So let's say that PE bails... Poof. No more Envision/TeamHealth.

What happens then; within realistic probability - ?

Honestly I see a big fat mess. My experience is that hospitals do an awful job employing docs and especially EM docs. Only the academic institutions do an OK job with this.

The hope of SDGs just popping up to take theplace of CMGs is unlikely simply because while it is relatively simple it takes a fair bit of time effort, knowledge and skill and I am unsure hospitals really want to provide the support needed. ACEP has their stupidly named "masterclass" for this but from what i heard it was fairly useful even if a bunch of lectures were by CMG clowns. AAEM has the AAEM-physician group but while I support AAEM i dont know how many people are familiar with this or have the interest in this. LAstly, there is a real financial issue with SDGs starting up. no insurance contracts, 3-6 months for revenue to roll in etc.


I would expect a mix of things happening. Some CMGs who dont falter picking up contracts. I could see a vituity benefitting greatly from this. They have no debt and are structured in a manner whereby they wont take bad contracts and get some buy in from the docs.

I can also see hospitals employing docs but frankly i dont see that as much better than the CMGs as hospitals are terrible at the $ side of EM and would look at this as a financial loser part of which might be true and part of which is because they dont know what they are doing.

So my answer is a weak non answer. I think we see a mix of things and I imagine it would. be location dependent. I dont think we will see PE re-enter the game.

I also see signficant paycuts to EM around the corner. Thats for all styles of employment. The $$ cuts to EM arent small. 10% all in from CMS, the NSA is wrecking the CMGs and of course MLPs and the glut of docs makes for a bad situation going forward.

The CMGs will cry poor as soon as they can, hospitals will then point to the updated MGMA data to force their cuts and SDGs will legit have lower revenue unless their income was already trash.

 

[Pudortu]

Honestly I see a big fat mess. My experience is that hospitals do an awful job employing docs and especially EM docs. Only the academic institutions do an OK job with this.

The hope of SDGs just popping up to take theplace of CMGs is unlikely simply because while it is relatively simple it takes a fair bit of time effort, knowledge and skill and I am unsure hospitals really want to provide the support needed. ACEP has their stupidly named "masterclass" for this but from what i heard it was fairly useful even if a bunch of lectures were by CMG clowns. AAEM has the AAEM-physician group but while I support AAEM i dont know how many people are familiar with this or have the interest in this. LAstly, there is a real financial issue with SDGs starting up. no insurance contracts, 3-6 months for revenue to roll in etc.


I would expect a mix of things happening. Some CMGs who dont falter picking up contracts. I could see a vituity benefitting greatly from this. They have no debt and are structured in a manner whereby they wont take bad contracts and get some buy in from the docs.

I can also see hospitals employing docs but frankly i dont see that as much better than the CMGs as hospitals are terrible at the $ side of EM and would look at this as a financial loser part of which might be true and part of which is because they dont know what they are doing.

So my answer is a weak non answer. I think we see a mix of things and I imagine it would. be location dependent. I dont think we will see PE re-enter the game.

I also see signficant paycuts to EM around the corner. Thats for all styles of employment. The $$ cuts to EM arent small. 10% all in from CMS, the NSA is wrecking the CMGs and of course MLPs and the glut of docs makes for a bad situation going forward.

The CMGs will cry poor as soon as they can, hospitals will then point to the updated MGMA data to force their cuts and SDGs will legit have lower revenue unless their income was already trash.

Wow Vituity doesn't have debt? They are gonna do very well.

I heard from my friend who is a medical director at Schumacher that directors across the country are getting up to a 25% paycut if they don't meet some certain/often times unattainable metrics.

I totally agree that there will be significant paycuts for EM coming soon. Just work hard, save money, and get to FI asap.

 

[southerndoc]

Wow Vituity doesn't have debt? They are gonna do very well.

I heard from my friend who is a medical director at Schumacher that directors across the country are getting up to a 25% paycut if they don't meet some certain/often times unattainable metrics.

I totally agree that there will be significant paycuts for EM coming soon. Just work hard, save money, and get to FI asap.

Site medical directors? I would resign from that position if they gave a 25% pay cut considering most MD/AMDs are already underpaid for the amount of time they put into a site. The medical directors at the corporate level? Yeah, go for it.

 

[NYEMMED]

Honestly I see a big fat mess. My experience is that hospitals do an awful job employing docs and especially EM docs. Only the academic institutions do an OK job with this.

The hope of SDGs just popping up to take theplace of CMGs is unlikely simply because while it is relatively simple it takes a fair bit of time effort, knowledge and skill and I am unsure hospitals really want to provide the support needed. ACEP has their stupidly named "masterclass" for this but from what i heard it was fairly useful even if a bunch of lectures were by CMG clowns. AAEM has the AAEM-physician group but while I support AAEM i dont know how many people are familiar with this or have the interest in this. LAstly, there is a real financial issue with SDGs starting up. no insurance contracts, 3-6 months for revenue to roll in etc.


I would expect a mix of things happening. Some CMGs who dont falter picking up contracts. I could see a vituity benefitting greatly from this. They have no debt and are structured in a manner whereby they wont take bad contracts and get some buy in from the docs.

I can also see hospitals employing docs but frankly i dont see that as much better than the CMGs as hospitals are terrible at the $ side of EM and would look at this as a financial loser part of which might be true and part of which is because they dont know what they are doing.

So my answer is a weak non answer. I think we see a mix of things and I imagine it would. be location dependent. I dont think we will see PE re-enter the game.

I also see signficant paycuts to EM around the corner. Thats for all styles of employment. The $$ cuts to EM arent small. 10% all in from CMS, the NSA is wrecking the CMGs and of course MLPs and the glut of docs makes for a bad situation going forward.

The CMGs will cry poor as soon as they can, hospitals will then point to the updated MGMA data to force their cuts and SDGs will legit have lower revenue unless their income was already trash.

Ive seen/ worked for some great hospital employed gigs. Guess it matters on where and the model.
Typically the hospital employed gigs had much better pay and coverage than CMG gigs, Until the CMGs came in and cut coverage in half and pay as well.

 

[xaelia]

Eventually these various indebted organizations will do what happens to everything that dies: they'll no longer be able to obtain those revolving loans required to provide liquidity to meet payroll. As cash flow gets harder – because accounts receivable across medicine is creeping upwards – and their credit sucks, they'll just stop being able to pay folks. Docs will show up for a few shifts in confusion, then there will be some Not Showing Up and panicked administrators will call around to other CMGs to try and come in to stabilize the situation.

I doubt it ends up being good for the docs, tho, regardless – organisational and systemic financial pain doesn't usually translate into great conditions on the ground.

 

[Pudortu]

Site medical directors? I would resign from that position if they gave a 25% pay cut considering most MD/AMDs are already underpaid for the amount of time they put into a site. The medical directors at the corporate level? Yeah, go for it.

Yes the site medical directors and it's reportedly going across company wide. I feel bad for them. Who knows whats happening at the corporate level...

 

[RustedFox]

Site medical directors? I would resign from that position if they gave a 25% pay cut considering most MD/AMDs are already underpaid for the amount of time they put into a site. The medical directors at the corporate level? Yeah, go for it.

Yeah, my current site director has the patience of Gandhi and the inner strength of a Dragonball-Z character.
No way s/he puts up with a pay cut.

 

[bravotwozero]

I really can’t see SDGs coming in to fill the void.

If large national CMGs have lost all bargaining power with insurers, then it stands to reason that SDGs will have even less bargaining power due to their smaller size.

 

[RustedFox]

I really can’t see SDGs coming in to fill the void.

If large national CMGs have lost all bargaining power with insurers, then it stands to reason that SDGs will have even less bargaining power due to their smaller size.

What we need is a national political figure to play hardball with the insurance companies and get them to do the right thing or else face actual criminal charges and sentencing for their various crimes.

 

[EctopicFetus]

Ive seen/ worked for some great hospital employed gigs. Guess it matters on where and the model.
Typically the hospital employed gigs had much better pay and coverage than CMG gigs, Until the CMGs came in and cut coverage in half and pay as well.

I know some great ones but when hospitals were making money it was easy for them to keep people happy. As they feel the financial pinch we will see what they do.

Outside of a few great gigs in undesirable locations they tend to be very benefit heavy and cash poor as jobs. Yes easy but generally pay was crap.

 

[EctopicFetus]

I really can’t see SDGs coming in to fill the void.

If large national CMGs have lost all bargaining power with insurers, then it stands to reason that SDGs will have even less bargaining power due to their smaller size.

Counter point and for consideration. I believe we will reach a point of rate setting. Insurers costs are capped by the nsa. Why would they be in network with anyone above that number (the qpa). Flip side is why would a group sign as it stands it will be below the qpa. Also the nsa guarantees adjustment for inflation.

Assuming you believe the above everyone will make the same per payer per equal patient.

Sdgs don’t require the same degree of overhead.

 

[Mount Asclepius]

If large national CMGs have lost all bargaining power with insurers, then it stands to reason that SDGs will have even less bargaining power due to their smaller size.

The reason SDGs have an advantage over CMGs is that there isn’t a middle man taking an unnecessary cut off the top. The cut they take is more than the advantage they provide by their bargaining power.

The problem in healthcare system wide is we have groups taking cuts off of people all over the place which doesn’t result in better care, just more business. It was a fair transaction when a patient paid their butcher surgeon with a chicken after they removed a bullet from their leg. Now we have insurers taking a cut, CMGs taking a cut, and hospitals taking a cut. What’s lost are physicians being paid for their expert opinion and hospitals with a mission providing truly non-profit care instead of being run as a money making business.

I’d fully support and agree with SDGs replacing CMGs, but I’m not sure that will happen. I suspect direct employment models are the more likely outcome. Streamlining health care direct to consumer (oh that made me cringe to say) will be the future of medicine. Think the Amazon of medicine.

 

[alpinism]

Yeah I find it hard to believe that SDGs will somehow begin replacing CMGs in the future.

Hell the LSU BR residency program was apparently just taken over by private equity.

 

[Rekt]

Yeah I find it hard to believe that SDGs will somehow begin replacing CMGs in the future.

Hell the LSU BR residency program was apparently just taken over by private equity.

Pretty much the only play. Residents are employed under the guise of a university, but all their work is billed under the CMG. Literally free indentured servitude for the CMG. They can employ less docs while residents cover the patients.

 

[NYEMMED]

The reason SDGs have an advantage over CMGs is that there isn’t a middle man taking an unnecessary cut off the top. The cut they take is more than the advantage they provide by their bargaining power.

The problem in healthcare system wide is we have groups taking cuts off of people all over the place which doesn’t result in better care, just more business. It was a fair transaction when a patient paid their butcher surgeon with a chicken after they removed a bullet from their leg. Now we have insurers taking a cut, CMGs taking a cut, and hospitals taking a cut. What’s lost are physicians being paid for their expert opinion and hospitals with a mission providing truly non-profit care instead of being run as a money making business.

I’d fully support and agree with SDGs replacing CMGs, but I’m not sure that will happen. I suspect direct employment models are the more likely outcome. Streamlining health care direct to consumer (oh that made me cringe to say) will be the future of medicine. Think the Amazon of medicine.

I can see the large insurers negotiating with hospital systems

“We will give you a 15% increased reimbursement, if you allow us to staff your ED”

And just like that, we all started working for insurance companies

 

[HemeOncHopeful19]

I can see the large insurers negotiating with hospital systems

“We will give you a 15% increased reimbursement, if you allow us to staff your ED”

And just like that, we all started working for insurance companies

The largest employer of physicians in the US is already Optum (United Healthcare).

 

[turkeyjerky]

I can see the large insurers negotiating with hospital systems

“We will give you a 15% increased reimbursement, if you allow us to staff your ED”

And just like that, we all started working for insurance companies

Would that be legal? Increased facility fee to gain staffing contract. I have a feeling that would run foul of some sort of antitrust law.

I agree that it's doubtful any SDGs rise out of the dust. When a CMG implodes, docs'll get employed by the hospital, or (more likely imo) scooped up by some ****tier, even less ethical CMG (EMA anyone???)

 

[NYEMMED]

Would that be legal? Increased facility fee to gain staffing contract. I have a feeling that would run foul of some sort of antitrust law.

I agree that it's doubtful any SDGs rise out of the dust. When a CMG implodes, docs'll get employed by the hospital, or (more likely imo) scooped up by some ****tier, even less ethical CMG (EMA anyone???)

I’m sure it is a violation of stark or anti-trust, as written. But I have no hesitation that these companies will figure it out somehow, probably with shell companies

 

[VA Hopeful Dr]

I’m sure it is a violation of stark or anti-trust, as written. But I have no hesitation that these companies will figure it out somehow, probably with shell companies

Yep. Humana, I mean CenterWell, already owns a huge number of outpatient primary care offices that service medicare patients.

 

[xaelia]

The largest employer of physicians in the US is already Optum (United Healthcare).

I actually liked working for Kaiser.

A lot different than working for Optum, I imagine.

 

[southerndoc]

I think insurance companies owning ED physician groups would probably get an investigation by the DoJ for antitrust violations. There would be too much power for the insurance company to persuade ED physicians to discharge patients, not order expensive tests, etc. A small number would go unnoticed. Some insurance companies already employ ED physicians (Kaiser comes to mind), but they are small in number and not attracting much attention right now.

 

[minor.groove]

I think insurance companies owning ED physician groups would probably get an investigation by the DoJ for antitrust violations. There would be too much power for the insurance company to persuade ED physicians to discharge patients, not order expensive tests, etc. A small number would go unnoticed. Some insurance companies already employ ED physicians (Kaiser comes to mind), but they are small in number and not attracting much attention right now.

Kaiser insurance doesn’t “own” the physician group from a purely legal standpoint- the physician group, hospital and insurance are three separate legal entities. But as said above the largest physician employer in the US is Sound who is owned by optium health who is owned by United.

 

[thegenius]

I think insurance companies owning ED physician groups would probably get an investigation by the DoJ for antitrust violations. There would be too much power for the insurance company to persuade ED physicians to discharge patients, not order expensive tests, etc. A small number would go unnoticed. Some insurance companies already employ ED physicians (Kaiser comes to mind), but they are small in number and not attracting much attention right now.

Kaiser doesn’t employ physicians, it’s TPMG that does. Totally separate companies. There is an exclusive contract between the two for TPMG to provide health care for the Kaiser members.

 

[southerndoc]

Kaiser doesn’t employ physicians, it’s TPMG that does. Totally separate companies. There is an exclusive contract between the two for TPMG to provide health care for the Kaiser members.

TPMG isn't owned by Kaiser? Apparently I have it all wrong.

 

[EMhawkeye]

By law in the state of California, hospitals can not directly employ physicians.
Kaiser concists of three entities which are legally separate companies: the medical group, the insurance company, the physical plants/ hospitals.

 

[southerndoc]

By law in the state of California, hospitals can not directly employ physicians.
Kaiser concists of three entities which are legally separate companies: the medical group, the insurance company, the physical plants/ hospitals.

This is how most health systems operate.

 

[NYEMMED]

By law in the state of California, hospitals can not directly employ physicians.
Kaiser concists of three entities which are legally separate companies: the medical group, the insurance company, the physical plants/ hospitals.

Yes, that’s the shells

They are all owned by the same parent company and have the same overall board.

This is the loophole they use to employ physicians directly

 

[EMhawkeye]

There pension plan can’t be beat. 2% per year vested pension until year 20 and then 1% per year there after.
Give them 30 years and you get 50% of your highest salary and free health insurance for life.

 

[EctopicFetus]

Kaiser is pure shenanigans. It’s easy work but it’s the same entity you work for don’t lie to yourself (or others).

 

[CoolDoc1729]

The hope of SDGs just popping up to take theplace of CMGs is unlikely simply because while it is relatively simple it takes a fair bit of time effort, knowledge and skill and I am unsure hospitals really want to provide the support needed. ACEP has their stupidly named "masterclass" for this but from what i heard it was fairly useful even if a bunch of lectures were by CMG clowns. AAEM has the AAEM-physician group but while I support AAEM i dont know how many people are familiar with this or have the interest in this. LAstly, there is a real financial issue with SDGs starting up. no insurance contracts, 3-6 months for revenue to roll in etc.

Also I don’t think most of the 30-50 crowd really wants to start and manage a group. I’m 10 years out, and I’d rather work for a SDG than a CMG but there’s no way I’d want to do the administrative work to manage the group. The younger docs at my site are certainly more clock in, clock out than I am. JMTC

 

[AlmostAnMD]

Also I don’t think most of the 30-50 crowd really wants to start and manage a group. I’m 10 years out, and I’d rather work for a SDG than a CMG but there’s no way I’d want to do the administrative work to manage the group. The younger docs at my site are certainly more clock in, clock out than I am. JMTC

I'm in that group and I feel the same way. I generally foresee the total collapse of emergency medicine as we know it sometime in the next decade. Between midlevel encroachment, cmgs churning out docs to exceed demand, falling reimbursements and a host of other factors not limited to castrated groups like ACEP....why would anyone like myself invest in this specialty? I'm a year away from paying off my medical school debt. After that I'm paying off my house. After that I'm out. Not gonna invest time and energy into a sinking ship.