CMG Reckoning

[Mount Asclepius]

Because the money in a SDG is better than the money in a CMG.

Because the profession of medicine is better than just chasing money.

Because a little bit of meaning in this world is better than the science of medicine.

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[Mount Asclepius]

I’m thumbs down on the future of emergency medicine and all of medicine. I don’t think it’s rock bottom yet though, and haven’t discovered anything else I’d rather do with my time yet. I’ve benefited a lot from being in a SDG and will sing their praises. I joined one with a wary, skeptical eye on the horizon. Over time I’ve found it incredibly worth it while I’ve seen former colleagues become ground up cogs at CMGs. Both environments can have good and bad options, but overall I truly believe SDGs are better aligned with the essence of being a physician in the truest sense.

 

[emergentmd]

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.

Risk reward is what matters at the end of the day. 20-30 yrs ago when CMGs had minimal penetration and insurance paid fairly, the rewards greatly outweighed the risk.

Now, the pendulum has swung the other way. The rewards are small and the risk are great. Imaging starting a SDG. Every time a new CEO comes in or your group doesn't do exactly what the CEO wants, you could have all the work/contract taken away. If the insurance company just wants to shut down a SDG, they could just delay payments for 6 months. With delayed payments, the SDG would have to go into debt or cut salary to NP rates. Most docs would flee getting paid $100/hr.

Anyone would be quite dumb to start a SDG esp in a major city where you have a target on your back. Do it in a rural area where CMGs want no part of it and you can have a sustainable model.

 

[turkeyjerky]

Risk reward is what matters at the end of the day. 20-30 yrs ago when CMGs had minimal penetration and insurance paid fairly, the rewards greatly outweighed the risk.

Now, the pendulum has swung the other way. The rewards are small and the risk are great. Imaging starting a SDG. Every time a new CEO comes in or your group doesn't do exactly what the CEO wants, you could have all the work/contract taken away. If the insurance company just wants to shut down a SDG, they could just delay payments for 6 months. With delayed payments, the SDG would have to go into debt or cut salary to NP rates. Most docs would flee getting paid $100/hr.

Anyone would be quite dumb to start a SDG esp in a major city where you have a target on your back. Do it in a rural area where CMGs want no part of it and you can have a sustainable model.

Ok Boomer... (/jk)

The problem with this argument is that the risks of not joining an SDG (let's be honest here, no one is starting any) are far greater than they were 20-30 years ago. Take a job w/ a CMG, and in a few years, you'll be making NP wages, seeing 3 pph in WR recliners and preparing to be served with your 4th suit in the past few years (all for patients whose care you were nominally involved in as a 'supervising' physician), not to mention practicing in a toxic environment where you can lose your job at any moment over a dissatisfied customer, despite having to work within the constrains of hospital policies and initiatives seemingly designed to ensure that no patient is satisfied.

 

[CajunMedic]

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

They kicked out their SDG? or did they get PE backing?

 

[emergentmd]

The problem with this argument is that the risks of not joining an SDG (let's be honest here, no one is starting any) are far greater than they were 20-30 years ago. Take a job w/ a CMG, and in a few years, you'll be making NP wages, seeing 3 pph in WR recliners and preparing to be served with your 4th suit in the past few years (all for patients whose care you were nominally involved in as a 'supervising' physician), not to mention practicing in a toxic environment where you can lose your job at any moment over a dissatisfied customer, despite having to work within the constrains of hospital policies and initiatives seemingly designed to ensure that no patient is satisfied.

All of the above is true with a SDG. SDG doesn't mean you make your own decision. All of the CEO's metrics, Sats, hospital policies doesn't change.
But you get the risk of not having money backers and constant threats of losing your contract. I would only start a SDG in a rural area where I know CMGs have little interests.

 

[EctopicFetus]

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.

It’s sad that we have been broken like this. I don’t blame you just saying it’s sad.
i know docs making insane em money but the clock in and clock out isn’t an answer for longevity or satisfaction. I get it.

 

[alpinism]

They kicked out their SDG? or did they get PE backing?

They basically sold out to ECP which is this new private equity backed CMG that focuses on small community hospitals.

 

[EctopicFetus]

They basically sold out to ECP which is this new private equity backed CMG that focuses on small community hospitals.

What does ecp stand for?

 

[Groove]

All of the above is true with a SDG. SDG doesn't mean you make your own decision. All of the CEO's metrics, Sats, hospital policies doesn't change.
But you get the risk of not having money backers and constant threats of losing your contract. I would only start a SDG in a rural area where I know CMGs have little interests.

I think that's the key statement. Somewhere CMGs aren't interested...which is proving more difficult to find these days. The thing that has always bothered me is that ED contract relationships are based on relationships with hospital administrators that are relatively transient. Someone might luck out on having a CEO that's at a hospital for 10+ years but the median tenure of most hospital CEOs is 3-5 years. All it takes is new hospital brass who might have a relationship with a certain CMG and/or becomes fixated on making the ED a pet "optimization" project and there goes the SDG. You would think that if you have good relationships with your specialists and private docs, their word might influence things but we had a local SDG much like this with terrible metrics yet great relationships with the docs and admin and my old CMG swooped in and took the contract with little to no resistance. The old group tried to galvanize the voice of the specialists/local PCPs that admitted there and it ultimately had very little effect.

I'm such a pro SDG person at heart but I have very little faith that docs will be able to retake our specialty and compete with PE. It's really our own fault. They prey on our apathy and relative lack of business accumen. They know that we might be smart and over achievers but at the end of the day, we all want to punch in and punch out and then turn off our phones. SDG requires a much greater investment in hospital politics and relations not to mention decent business skills. The tenure thing bothers me the most. Every time I see a partnership track where it's going to take me 4-6 years to recoup, I always wonder how the group can guarantee they will still be there...

 

[alpinism]

What does ecp stand for?

Emergency Care Partners Company Profile: Funding & Investors | PitchBook

Information on valuation, funding, acquisitions, investors, and executives for Emergency Care Partners. Use the PitchBook Platform to explore the full profile.

pitchbook.com

 

[EctopicFetus]

Emergency Care Partners Company Profile: Funding & Investors | PitchBook

Information on valuation, funding, acquisitions, investors, and executives for Emergency Care Partners. Use the PitchBook Platform to explore the full profile.

pitchbook.com

Anyone who continues to wonder the acep cmg relationship. It’s like a training ground for these clowns. How to abuse your fellow docs.

 

[NYEMMED]

Anyone who continues to wonder the acep cmg relationship. It’s like a training ground for these clowns. How to abuse your fellow docs.
View attachment 362449

A true clown right here:

Look up what he did with Prime and Legacy Physician Partners outside Philly, talk about predatory… after a string of takeovers with huge cuts in NY

 

[xaelia]

Seems a bit of issue re: "saving the specialty" is that ACEP et al are struggling because they are sort of trying to assert a sort of monopoly power on staffing the market doesn't want/need.

99% of patients want cheap, on-demand care that matches what they already determined they need from Google. Amazon Clinic, Urgent Cares, EDs full of MLPs can write those scripts, sew up a finger, give them a note for work. An MLP on rails can order a lactate/BCx/fluids, a troponin/BNP/D-dimer, or an abdominal/renal CT, good enough for 90%+ of actual "emergency medicine".

We all know, in any average department, that still means several patients per day who need an actual ABEM to sort out complicated issues, or perform critical procedures – but it doesn't justify putting nearly as many emergency docs on staff 24/7 for "physician-led teams" as the current status quo. No amount of ACEP PR will sell that. And, then the training programs just keep churning out more ...

 

[HemorrhagicShock]

99% of patients want cheap, on-demand care that matches what they already determined they need from Google. Amazon Clinic, Urgent Cares, EDs full of MLPs can write those scripts, sew up a finger, give them a note for work. An MLP on rails can order a lactate/BCx/fluids, a troponin/BNP/D-dimer, or an abdominal/renal CT, good enough for 90%+ of actual "emergency medicine".

We all know, in any average department, that still means several patients per day who need an actual ABEM to sort out complicated issues, or perform critical procedures – but it doesn't justify putting nearly as many emergency docs on staff 24/7 for "physician-led teams" as the current status quo. No amount of ACEP PR will sell that. And, then the training programs just keep churning out more ...

I wish more people understood this. It's 100% correct. A good 90% of our volume will get a "reasonable" standard of care via MLP-and-orderset-driven medicine. A bulk of the diagnosing comes purely from abnormal labs and radiology reads. No MLP routinely considers things at a deeper level, and a vast majority don't have that ability based on their training.

The bottom line is that system will not bear MD/DO physician costs to find the 10% of patients that require an ABEM-trained physician.

 

[thegenius]

I agree with the prior two posts except percentage. It’s probably more like 70%. Which is actually sizable.

What’s sad is what does this say about emergency medicine itself? As I’ve written in the past as it’s currently constructed - it’s a failed paradigm. Frankly I think urgent care is a failed paradigm too as most of these people don’t need urgent care. They don’t need any care at all.

The only way this will change is to shift cost directly to the consumer. If people want to spend 100% of urgent care with their own money, I’m totally fine by that.

 

[Arcan57]

I agree with the prior two posts except percentage. It’s probably more like 70%. Which is actually sizable.

What’s sad is what does this say about emergency medicine itself? As I’ve written in the past as it’s currently constructed - it’s a failed paradigm. Frankly I think urgent care is a failed paradigm too as most of these people don’t need urgent care. They don’t need any care at all.

The only way this will change is to shift cost directly to the consumer. If people want to spend 100% of urgent care with their own money, I’m totally fine by that.

You’re vastly overestimating how functional the outpatient system is here. Something needs to fill in gap between no care and “our next appointment is in 4 months on a random weekday during work hours”. The payers are trying a variety of cheap options to fill that gap, but their dominant paradigm is tele health which under current perceptions of legal risk is actually going to increase UC/ED visits.

 

[turkeyjerky]

You’re vastly overestimating how functional the outpatient system is here. Something needs to fill in gap between no care and “our next appointment is in 4 months on a random weekday during work hours”. The payers are trying a variety of cheap options to fill that gap, but their dominant paradigm is tele health which under current perceptions of legal risk is actually going to increase UC/ED visits.

I do have to say, it's rather shocking the number of times I've seen a patient the same day that they've both been to an UC and seen a teledoc. (Although, it's not shocking that the inevitable outcome is that I tell them they don't need to fill the Rx that was written).

 

[Restart13]

I think some of the future bears responsible ordering and diagnosing. I can see/order/dispo patients way more effectively and efficiently than MLPs. I foresee a future where insurance companies will incentivize mindful workups to lower costs. In that sense, I think a physician mindset comes in. MLPs are great from an employer standpoint, but as a system standpoint, do they really save much money? Or at the very least in the current staffing model do they save much money?

That being said, you can't really do too much without tort reform.

 

[Restart13]

Emergency Care Partners Company Profile: Funding & Investors | PitchBook

Information on valuation, funding, acquisitions, investors, and executives for Emergency Care Partners. Use the PitchBook Platform to explore the full profile.

pitchbook.com

My "SDG" is contemplating selling to these guys. I'm still on track so I get no vote/nothing. Some of their pros they advertise is some form of shareholder status/future ability to buy in. no idea on dividends on said shares, or what it really means. Would love to actually talk to someone who was part of said group(s) that ended up selling.

 

[Brigade4Radiant]

Seems a bit of issue re: "saving the specialty" is that ACEP et al are struggling because they are sort of trying to assert a sort of monopoly power on staffing the market doesn't want/need.

99% of patients want cheap, on-demand care that matches what they already determined they need from Google. Amazon Clinic, Urgent Cares, EDs full of MLPs can write those scripts, sew up a finger, give them a note for work. An MLP on rails can order a lactate/BCx/fluids, a troponin/BNP/D-dimer, or an abdominal/renal CT, good enough for 90%+ of actual "emergency medicine".

We all know, in any average department, that still means several patients per day who need an actual ABEM to sort out complicated issues, or perform critical procedures – but it doesn't justify putting nearly as many emergency docs on staff 24/7 for "physician-led teams" as the current status quo. No amount of ACEP PR will sell that. And, then the training programs just keep churning out more ...

This applies to a lot of outpatient specialists as well it’s just that we gate keep other physicians but MLP can do 80% of derm and other outpatient specialties

 

[BoardingDoc]

but as a system standpoint, do they really save much money? Or at the very least in the current staffing model do they save much money?

No, they are more expensive in the end.

The Productivity of Professions: Evidence from the Emergency Department

Founded in 1920, the NBER is a private, non-profit, non-partisan organization dedicated to conducting economic research and to disseminating research findings among academics, public policy makers, and business professionals.

www.nber.org

Takeaway quote: analysis suggests a net increase in medical costs with NPs, even when accounting for NPs’ wages that are half as much as physicians’

 

[NYEMMED]

My "SDG" is contemplating selling to these guys. I'm still on track so I get no vote/nothing. Some of their pros they advertise is some form of shareholder status/future ability to buy in. no idea on dividends on said shares, or what it really means. Would love to actually talk to someone who was part of said group(s) that ended up selling.

They will place the buy in so ridiculously high, cut your overall pay, they will fire your leaders over time and replace them with their own lackeys that will do as told.
They will cut your coverage, and the value of your buy in is worthless as they will have convenient evaluations that favor the company not paying out.

Everything they say has to be in writing, to avoid a bait and switch

 

[EctopicFetus]

Collateralised fund obligations: how private equity securitised itself

Stakes in hundreds of buyout groups’ companies have been bundled into investments with strong credit ratings

www.ft.com

The US hospital staffing company Envision Healthcare, owned by the private equity firm KKR, has the lowest possible junk-grade credit rating and is at risk of bankruptcy, according to Moody’s.

 

[NYEMMED]

Collateralised fund obligations: how private equity securitised itself

Stakes in hundreds of buyout groups’ companies have been bundled into investments with strong credit ratings

www.ft.com

The US hospital staffing company Envision Healthcare, owned by the private equity firm KKR, has the lowest possible junk-grade credit rating and is at risk of bankruptcy, according to Moody’s.

See ya!

No loss for us!

 

[xaelia]

See ya!

No loss for us!

My MBA wife says – well, if these companies treat their docs like disposable garbage, how could your lives get worse when they go bankrupt? What did docs do before CMGs came along? Just go back to independent groups? Hospital employees? If these for-profit CMGs were taking all your money, maybe you'll get paid more and treated better?

 

[NYEMMED]

My MBA wife says – well, if these companies treat their docs like disposable garbage, how could your lives get worse when they go bankrupt? What did docs do before CMGs came along? Just go back to independent groups? Hospital employees? If these for-profit CMGs were taking all your money, maybe you'll get paid more and treated better?

The hospitals always need EM docs. There will always be somebody to work for.

 

[CoolDoc1729]

My MBA wife says – well, if these companies treat their docs like disposable garbage, how could your lives get worse when they go bankrupt? What did docs do before CMGs came along? Just go back to independent groups? Hospital employees? If these for-profit CMGs were taking all your money, maybe you'll get paid more and treated better?

I feel like I was sitting at work in December of 2020 thinking how could work get worse? But it certainly has.

If the cmgs go under , it will eventually be good for us (I think) but in the short term I’m not looking forward to paycheck interruptions tbh

 

[xaelia]

The hospitals always need EM docs. There will always be somebody to work for.

Obviously.

But hospitals always need nurses – it hasn't exactly been shaping up in their favor without a lot of angst, pain, and Not Showing Up.

And most hospitals are running deep in the red this year.

 

[EctopicFetus]

Obviously.

But hospitals always need nurses – it hasn't exactly been shaping up in their favor without a lot of angst, pain, and Not Showing Up.

And most hospitals are running deep in the red this year.

But the nurses are making doctor dough. Yes they are breaking the hospitals but it’s not like the insurers aren’t making record profits.

 

[xaelia]

But the nurses are making doctor dough. Yes they are breaking the hospitals but it’s not like the insurers aren’t making record profits.

Yeh, I'm not sure exactly how it will work.

Obviously, there's some supply and demand. Certain service lines generate more revenue for hospitals than others. Patient payor mix and referral network comes from different sources. It's not inconceivable a hospital, faced with significant short-term wreckage in the ED, simply shuts it down (assuming that's actually legal).

We're clearly going to start finding out – as you note, insurers are squeezing and making huge profits, reimbursements are changing, marketplace competition is peeling off the folks who can easily pay, and hospitals are running in the red.

 

[EctopicFetus]

Yeh, I'm not sure exactly how it will work.

Obviously, there's some supply and demand. Certain service lines generate more revenue for hospitals than others. Patient payor mix and referral network comes from different sources. It's not inconceivable a hospital, faced with significant short-term wreckage in the ED, simply shuts it down (assuming that's actually legal).

We're clearly going to start finding out – as you note, insurers are squeezing and making huge profits, reimbursements are changing, marketplace competition is peeling off the folks who can easily pay, and hospitals are running in the red.

Atlanta Medical Center did this.. just shut down. plenty of volume but garbage payer mix.

 

[RustedFox]

Yeh, I'm not sure exactly how it will work.

Obviously, there's some supply and demand. Certain service lines generate more revenue for hospitals than others. Patient payor mix and referral network comes from different sources. It's not inconceivable a hospital, faced with significant short-term wreckage in the ED, simply shuts it down (assuming that's actually legal).

We're clearly going to start finding out – as you note, insurers are squeezing and making huge profits, reimbursements are changing, marketplace competition is peeling off the folks who can easily pay, and hospitals are running in the red.

What we really need is a way to get the insurers to play fair. They're the BigBadEvil in this.

 

[TooMuchResearch]

I

My "SDG" is contemplating selling to these guys. I'm still on track so I get no vote/nothing. Some of their pros they advertise is some form of shareholder status/future ability to buy in. no idea on dividends on said shares, or what it really means. Would love to actually talk to someone who was part of said group(s) that ended up selling.

It means you're getting screwed and everyone close to retirement is getting their buy out.

 

[ScepticSkeksis]

I

It means you're getting screwed and everyone close to retirement is getting their buy out.

Seems like we will always get screwed no matter what. I don't think it will be any better with hospital employment. Trading one big, evil corporation for another doesn't seem like an improvement. I'm jealous of all of you who are near to retirement and can get out.