Decrease in EP salaries/pay?

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futureemdoc1

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So with all the fear mongering going on with midlevels taking EP jobs... has anyone actually seen or heard of a decrease in pay for EP's now that NP's and PA's are becoming more prevalent in the ED?
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Part of this answer depends on whether you own your group or are an employee. Adding midlevels has greatly increased our hourly pay in my SDG.


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Well it can however in high acuity shops EM docs can’t be replaced. It would be best to make your money now. Making predictions on medical fields in the distant future is hard. New laws can destroy CMGs or SDGs or strengthen them.
 
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The rate of my raises has decreased, but my pay continues to increase.

I don't worry, but I do save aggressively.
 
Yeah all I've seen over my decade in EM is a continual rise in salary. Doesn't mean it will always be that way, and there will be wild variations depending on the location and setting (CMG, SDG, employee). But as a whole, the salaries have gone up. Will that always be the case? If not, how long before the bubble bursts? I don't know. Medicine is too unpredictable because our payments are tied in large part to our governments rules and legislation. That stuff can change at any time, so it makes long term planning impossible. All you can do is make money while you can and invest for your retirement. Worrying about future salary prospects is worthless, because its totally out of our hands, unless you believe that the AMA and our individual lobbying bodies will actually be able to get the govt to have the best interests of physicians in mind when the upend the healthcare system again (and again and again and again).
 
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Our field is on the same course as radiology and anesthesiology. These fields seemed like there would never be a ceiling in terms of pay. Then one day, the bubble popped.

Like anesthesia, a huge part of the issue is midlevels. The EM bubble will inevitably pop. This is not just the typical "doom and gloom" mindset of SDN, but rather, simple economics and a little bit of historical context.

For whatever reason, the vast majority of current EM physicians continue to tell prospective medical students and those applying that EM docs are the highest in demand docs out of any specialty and how "you will always have a job". While that may be the situation currently, who knows how things will pan out.

Also, geography plays a huge role in terms of EM compensation. I have talked to EM physicians in highly competitive markets, where supply and demand economics favors the employers. They are noticing their salaries taking a hit when there's someone else who is willing to do your job for less money just so they can live by the beach.
 
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TheComebacKid said:
Our field is on the same course as radiology and anesthesiology. These fields seemed like there would never be a ceiling in terms of pay. Then one day, the bubble popped.

Like anesthesia, a huge part of the issue is midlevels. The EM bubble will inevitably pop. This is not just the typical "doom and gloom" mindset of SDN, but rather, simple economics and a little bit of historical context.

For whatever reason, the vast majority of current EM physicians continue to tell prospective medical students and those applying that EM docs are the highest in demand docs out of any specialty and how "you will always have a job". While that may be the situation currently, who knows how things will pan out.

Also, geography plays a huge role in terms of EM compensation. I have talked to EM physicians in highly competitive markets, where supply and demand economics favors the employers. They are noticing their salaries taking a hit when there's someone else who is willing to do your job for less money just so they can live by the beach.
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Not too long ago I posted this: Are locums rates really declining?
 
We use APPs extensively and we make a tremendous amount of money because of them. Everyone of them is scared out of their mind running an ED by themselves. As long as our group is around I am not worried about APP take over. Now, if we sold out to the hospital or lost our contracts than that is another story, but I still think the sky is falling mentality is a little overblown. If you work away from the coasts and mountains you can easily make 400k and if you work hard 500k is doable. People who choose to live in competitive markets and desirable areas will make a lot less, but I guess that is the tax they choose to pay. I will always recommend living in fly over states and make twice as much and then vacation every month of the year. Will those salaries be around in 10 years, probably not, but will we all be making 150k, I don't think so. I think it is reasonable to expect 300-350k a year for much less work than the avg speciality. Will ortho pods and Mohs and rad onc make more, of course they will, but I don't see EM pay crashing to sub PA pay or primary care pay anytime soon.
 
I have worked a lot with individuals and organizations on NP and PA integration. With that being said, I would not worry about a shift in EP salaries. First, ED salaries are driven by the need for physicians and the shortage of physicians. The introduction of NPs and PAs might influence that but largely it impacts access and delivery of care time, not the decreased need for physicians. Second, and fortunately, ED physician need is driven by medical staff rules. In other words, Medical Staffs make their own rules on who can admit, see patients, and so on. While NPs and PAs have been allowed to see patients in the ED, it is extremely rare (rural South Dakota) for a Medical Staff to not require a physician to be on-site. Finally, ED physicians are largely still in private practice and the market is virtually controlled by physician owned entities. Therefore, even if point #1 was not true, physicians are still controlling the delivery of labor. The bottom line is that from a market perspective, salaries are not going down for ED physicians, stagnating perhaps though.
 
See... you went and said "ED Physicians are largely in private practice".

Ima stop you right there, chief.
 
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Provider Career Advisor said:
I have worked a lot with individuals and organizations on NP and PA integration. With that being said, I would not worry about a shift in EP salaries. First, ED salaries are driven by the need for physicians and the shortage of physicians. The introduction of NPs and PAs might influence that but largely it impacts access and delivery of care time, not the decreased need for physicians. Second, and fortunately, ED physician need is driven by medical staff rules. In other words, Medical Staffs make their own rules on who can admit, see patients, and so on. While NPs and PAs have been allowed to see patients in the ED, it is extremely rare (rural South Dakota) for a Medical Staff to not require a physician to be on-site. Finally, ED physicians are largely still in private practice and the market is virtually controlled by physician owned entities. Therefore, even if point #1 was not true, physicians are still controlling the delivery of labor. The bottom line is that from a market perspective, salaries are not going down for ED physicians, stagnating perhaps though.
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You are pretty far off. Many ED physicians are employed by hospitals or contract management groups (CMG's). Some are part of small democratic groups (SDG's). Almost half are independent contractors (IC's) for CMG's as they operate nearly half the ER's in this country.

You miss the point I made in my other thread: telemedicine will not occur overnight. The first step is increasing APP staffing in ED's to replace ER physicians. It's already starting. The difference at first will not be between a doc on-site and a doc off-site. It will be the difference between 2 ER docs vs 1 ER doc. In places that normally have 3 ER docs staffing the ER at any given time, there might be 6 APP's with 1 ER doc supervising them. Ten years from now it will be remote supervision in many rural ER's.
 
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southerndoc said:
You are pretty far off. Many ED physicians are employed by hospitals or contract management groups (CMG's). Some are part of small democratic groups (SDG's). Almost half are independent contractors (IC's) for CMG's as they operate nearly half the ER's in this country.

You miss the point I made in my other thread: telemedicine will not occur overnight. The first step is increasing APP staffing in ED's to replace ER physicians. It's already starting. The difference at first will not be between a doc on-site and a doc off-site. It will be the difference between 2 ER docs vs 1 ER doc. In places that normally have 3 ER docs staffing the ER at any given time, there might be 6 APP's with 1 ER doc supervising them. Ten years from now it will be remote supervision in many rural ER's.
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I do not disagree and I am not saying none are hospital employed. I simply am stating that on the spectrum of specialties still having a stronghold on private practice/CMG (which I view as close to the same considering many CMGs are physician owned), ED physicians are one. Unlike family medicine, pediatrics, and so on. But yes, I agree.
 
Provider Career Advisor said:
I do not disagree and I am not saying none are hospital employed. I simply am stating that on the spectrum of specialties still having a stronghold on private practice/CMG (which I view as close to the same considering many CMGs are physician owned), ED physicians are one. Unlike family medicine, pediatrics, and so on. But yes, I agree.
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Provider Career Advisor said:
I do not disagree and I am not saying none are hospital employed. I simply am stating that on the spectrum of specialties still having a stronghold on private practice/CMG (which I view as close to the same considering many CMGs are physician owned), ED physicians are one. Unlike family medicine, pediatrics, and so on. But yes, I agree.
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The cmgs are owned by private equity. Local docs have nothing but the illusion of control.
 
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Provider Career Advisor said:
I do not disagree and I am not saying none are hospital employed. I simply am stating that on the spectrum of specialties still having a stronghold on private practice/CMG (which I view as close to the same considering many CMGs are physician owned), ED physicians are one. Unlike family medicine, pediatrics, and so on. But yes, I agree.
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CMG isn't anywhere close to private practice. Are you a physician?
 
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dav86 said:
We use APPs extensively and we make a tremendous amount of money because of them. Everyone of them is scared out of their mind running an ED by themselves. As long as our group is around I am not worried about APP take over. Now, if we sold out to the hospital or lost our contracts than that is another story, but I still think the sky is falling mentality is a little overblown. If you work away from the coasts and mountains you can easily make 400k and if you work hard 500k is doable. People who choose to live in competitive markets and desirable areas will make a lot less, but I guess that is the tax they choose to pay. I will always recommend living in fly over states and make twice as much and then vacation every month of the year. Will those salaries be around in 10 years, probably not, but will we all be making 150k, I don't think so. I think it is reasonable to expect 300-350k a year for much less work than the avg speciality. Will ortho pods and Mohs and rad onc make more, of course they will, but I don't see EM pay crashing to sub PA pay or primary care pay anytime soon.
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Are these APPs actually supervised by you? Are you willing to take on the liability when they make a mistake? Anytime you do anything for money you are setting yourself up for failure. APPs are already not supervised in 22 states. The NP organization is already gearing up for this legislative season in supervised states. And PAs are following suit. We already know of one state that is going to grant PAs independence. But I am so glad that you made a tremendous amount of money.
 
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RustedFox said:
CMG isn't anywhere close to private practice. Are you a physician?
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Not saying it is the same as private wholly owned partner/physician owned entity. I am simply saying many CMGs have physician ownership opportunities. No, but this also is not a thread comparing CMGs and partner-owned group.
 
Indebt4Life said:
Are these APPs actually supervised by you? Are you willing to take on the liability when they make a mistake? Anytime you do anything for money you are setting yourself up for failure. APPs are already not supervised in 22 states. The NP organization is already gearing up for this legislative season in supervised states. And PAs are following suit. We already know of one state that is going to grant PAs independence. But I am so glad that you made a tremendous amount of money.
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The way it's structured, even if given legal autonomy, it would be almost impossible for a hospital to hire APPs to uncercut us. Typically the CMGs getting an ED contract have an exclusive right to staff the ED, which means that any APPs are employed, and supervised by the ED physicians at the CMG. Use of APPS is what has (temporarily) nearly doubled my salary from 5 years ago.
 
Provider Career Advisor said:
Not saying it is the same as private wholly owned partner/physician owned entity. I am simply saying many CMGs have physician ownership opportunities. No, but this also is not a thread comparing CMGs and partner-owned group.
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2d0vme.jpg



See, you went wrong again with "Many CMGs have physician ownership opportunities".
The only one that is immediately on any doc's mind is "USACS", and we know what kind of a laughable ownership scam that is.

I'm gonna call you out.
Declare yourself and what you know/how you know it, because right now - nothing you say passes the sniff test to me or any other EM attending on this forum.
 
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Indebt4Life said:
Are these APPs actually supervised by you? Are you willing to take on the liability when they make a mistake? Anytime you do anything for money you are setting yourself up for failure. APPs are already not supervised in 22 states. The NP organization is already gearing up for this legislative season in supervised states. And PAs are following suit. We already know of one state that is going to grant PAs independence. But I am so glad that you made a tremendous amount of money.
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All of our APPs are supervised except at one shop where they do our fast track. I see all of their medicare/medicaid/anthem pts and any pts where they have questions. Anyone not using APPs to make money is already behind. Luckily in our group I and other physicians benefit instead of being hospital employed and the hospital benefiting. You could maybe make the argument that the APP revolution should never have started, but that happened before my time. Our goal is to provide the best care we can and make as much money as we can before the game changes. The game will change, but I don't think it will be as big of a change as some think nor will it happen as fast as some think. Again, will we be SDG forever, probably not. Will I make the money I made in 2018 again, probably not. Will PA/NPs be taking my job in the next two years, probably not. Like others have mentioned, significant hospital bylaw changes would have to occur and significant state/national legislative changes would have to be made and even if those changes were made I don't think as many APPs would be itching to practice solo. Not one of our 40 APPs wants to practice medicine solo, or through tele medicine. We practice in one of the best states for tort reform and they are still scared out of their mind to miss something or have to intubate the 3 yo or have to run a code by themselves, etc. NPs getting full solo practice rights...sure it is happening, but am I worried about them taking my job...hell no. NPs run all of the UCs around our shops and they transfer BS 100% of the time. Not only will cost go up if NPs practiced solo in the ED, but ppl would die, things would get missed. It would last less than a yr before class action suits start hitting hospital systems for millions of dollars. I think there will always be a role for physicians in our system. Again, maybe pay goes down a bit and supervision of APPs becomes common place but physician training will always be necessary.
 
RustedFox said:
2d0vme.jpg



See, you went wrong again with "Many CMGs have physician ownership opportunities".
The only one that is immediately on any doc's mind is "USACS", and we know what kind of a laughable ownership scam that is.

I'm gonna call you out.
Declare yourself and what you know/how you know it, because right now - nothing you say passes the sniff test to me or any other EM attending on this forum.
Click to expand...
So just to be clear, it is ownership right? Or is it control? Because those are different. I just simply stated ownership opportunities.
 
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Provider career advisor. I’ll say it. Your posts show a lack of understanding of em economics.
 
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GeneralVeers said:
I'm in agreement. The biggest threat right now are the residency mills being started on a massive scale by CMGs.
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Agreed, CMG residency proliferation combined with huge and insane levels of debt from for-profit medschools and the paucity of easy exits from EM is making for a toxic stew.
 
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miacomet said:
Agreed, CMG residency proliferation combined with huge and insane levels of debt from for-profit medschools and the paucity of easy exits from EM is making for a toxic stew.
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This should be a big worry. I do have significant concerns about that. Agreed.
 
miacomet said:
Agreed, CMG residency proliferation combined with huge and insane levels of debt from for-profit medschools and the paucity of easy exits from EM is making for a toxic stew.
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Are the for profit med schools the carribean ones? I don’t think us md schools are for profit? Maybe I’m missing something.
 
Apollyon said:
Rocky Vista University College of Osteopathic Medicine, Colorado and Utah (DO).

California Northstate University College of Medicine (MD).

Theses are the only 2.
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Yup, and easily googled @EctopicFetus :)

But this is a major change. The Flexner Report banned for-profit schools in the US for over a century, so this is a big, and unfortunate, deal.

I work with midlevel students from RV. They are very, very bad.They seem to accept anyone and they don't train them.
 
Apollyon said:
Rocky Vista University College of Osteopathic Medicine, Colorado and Utah (DO).

California Northstate University College of Medicine (MD).

Theses are the only 2.
Click to expand...
Ponce School of Medicine, Puerto Rico (MD)

Burrell College of Osteopathic Medicine, New Mexico (DO)

Idaho College of Osteopathic Medicine (Idaho, obviously)



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Btw, the for-profit hospital proliferation of residency programs is not restricted to EM. For-profit hospitals are opening IM, FM, and surgery in Idaho, Utah, Florida, Arizona... probably more.

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Note to self.. never hire anyone or match anyone into residency from these places.
 
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EctopicFetus said:
Note to self.. never hire anyone or match anyone into residency from these places.
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Unfortunately, the actual designation of these schools doesn't mean anything. Almost all schools are for-profit. I rotated with a loose-lipped FM doc that headed the opening of three new schools. In two years all his schools had debts paid off, in 3-4 years they're all making significant profit. None of his schools have been mentioned in this thread.
 
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EMhopeful2 said:
Maybe, but their recent match list shows students matching to some pretty strong places like hennepin and indiana. Even students where I go (good MD school) don't match that well.
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That's because the top of their class is doing EM, not MD ortho or ENT. My guess is the top of your class is doing surgical subspecialties, derm, and high end IM at fancy MD programs. I don't think you will see RV grads going to Mass General for gen surg. Although I agree, there are some surprisingly good matches from their 2016 list (easiest to find), like U Chicago for IM and Baylor for gen surg. No great EM matches on that list, though.

When the matches combine, though, I think you will see a drop off.
 
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futureemdoc1 said:
So with all the fear mongering going on with midlevels taking EP jobs... has anyone actually seen or heard of a decrease in pay for EP's now that NP's and PA's are becoming more prevalent in the ED?
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Well, salaries have certainly been mostly flat for the past five years or so. What has happened to the cost of everything else during that time period?
 
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Even with the massive explosion of residencies, it's hard to get docs to work EM and EM shifts. It's only easy to get midlevels because they cherry-pick their diva shifts. If the US continues to demand 24/7 staffing of their ERs with attendings, then (unless us docs are completely obtuse, which I don't rule out), EM will have to pay semi-decently or folks will peel off into telehealth, urgent care, occ med etc. The exit strategies from EM are few, but they are increasing, and new grads seem to be thinking of exit strategies earlier and earlier. So I don't see salaries declining horribly unless we just stop staffing ERs, which is, I suppose, possible.
 
miacomet said:
Even with the massive explosion of residencies, it's hard to get docs to work EM and EM shifts. It's only easy to get midlevels because they cherry-pick their diva shifts. If the US continues to demand 24/7 staffing of their ERs with attendings, then (unless us docs are completely obtuse, which I don't rule out), EM will have to pay semi-decently or folks will peel off into telehealth, urgent care, occ med etc. The exit strategies from EM are few, but they are increasing, and new grads seem to be thinking of exit strategies earlier and earlier. So I don't see salaries declining horribly unless we just stop staffing ERs, which is, I suppose, possible.
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What are the exit strategies other than live like an ascetic for 10 years and hope that you can put away enough to last you until you die?
 
bronx43 said:
What are the exit strategies other than live like an ascetic for 10 years and hope that you can put away enough to last you until you die?
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Pain, hyperbarics, wound care, addiction medicine, telehealth, occupational medicine, urgent care, admin, public health etc. Yes, they all pay less, but a better schedule and lower stress. I agree EM is not rife with great exit strategies and is a fraud of a field that you can't do long term, but if you can earn 400k a year (unlikely if you are in the Bronx!), save up a couple million over a decade, and then retire to a cush job where you earn 150-200k, life is sweet, no?

Disagree, BTW, that salaries have been flat. The last two to three years they've flattened, but NYC pays much more than it used to.
 
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miacomet said:
Pain, hyperbarics, wound care, addiction medicine, telehealth, occupational medicine, urgent care, admin, public health etc. Yes, they all pay less, but a better schedule and lower stress. I agree EM is not rife with great exit strategies and is a fraud of a field that you can't do long term, but if you can earn 400k a year (unlikely if you are in the Bronx!), save up a couple million over a decade, and then retire to a cush job where you earn 150-200k, life is sweet, no?

Disagree, BTW, that salaries have been flat. The last two to three years they've flattened, but NYC pays much more than it used to.
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But this is my point... the main exit strategy is still to live cheap and save up as quickly as you can, so that you don't have to run the rat race for the rest of your life. There is no large scale exit strategy for EM or any other field in general, as none of those other fields/jobs that you mentioned can accommodate large influx. These are already niche markets with established players.
 
bronx43 said:
But this is my point... the main exit strategy is still to live cheap and save up as quickly as you can, so that you don't have to run the rat race for the rest of your life. There is no large scale exit strategy for EM or any other field in general, as none of those other fields/jobs that you mentioned can accommodate large influx. These are already niche markets with established players.
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You'd be surprised what urgent care could accommodate.
 
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I have always wanted to do Sports Medicine, so I'm glad to see this is a fellowship option for EM. Does anyone have any insight into how working SM along with EM would affect your salary? I imagine it'd be lower... but how do you get the ED you work with to allow you to cherry pick shifts to be suitable for picking up shifts at an 8-5 job elsewhere like 1-2 times a week?
 
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