Firefighter position with Team Health

[EctopicFetus]

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Which is why the CMGs are going to win or force the SDGs to become just like them. While it's unnecessary overheard for a completely secure contract (if such a thing exists), having someone who's main income derives from keeping the contract fosters a certain dedication towards keeping that contract. It's unlikely that someone is going to "volunteer" to be the doc that is in charge of quality for an entire system. Things that can be easily divided up by an SDG at a single hospital like locking down the key committees (med exec, P&T, peer review, +/- trauma/cards) aren't workable at a system level without a heavy subsidy to the person(s) in charge of coordinating things. Now maybe you have a close partnership with the system and they're doing the heavy lifting on quality reporting and compliance. That's going to be at least a potential source of vulnerability because the large CMGs are going to be able to handle that in-house which means less money the system is spending on it.

If you can find a true SDG that's willing to hire you out of residency in a place you want to live with a decent work environment that doesn't require an extended period of indentured servitude then go for it (really, jump on that). But don't sign with what I'll call a quasi-SDG (closed books, only one or a small handful of owners, hx of releasing docs just before making partner, etc) if a true SDG isn't available just because they're not a CMG.

I disagree. I know I am in a special spot. I honestly dont get why more groups cant be like mine. We do have an extended period of time where you work for below market. This sucks but it prevents people from coming in and working for a bit and leaving. We are ridiculously stable. No one has left this job for another clinical job in 7-8 years. Not a single physician in my group gets over 30% of their income from admin pay. Some jobs get paid for by us internally. When you have 30-60 people who care you have an executive team who are paid. They deal with your day to day. others volunteer. My group an SDG has an internal quality director.

I agree about the fake or quasi SDG. once a partner in my group the books are completely open. I know to the penny what every doc in my group made. I know how many hours they work. honestly, my point isnt to come on here and tell everyone what my group looks like but rather to wonder why more arent like us. Its a sad and scary state or affairs.

 

[@JackShephard]

Birdstrike, I'd agree with your opinion that they created the company and arguably have a skillset that others lack. My problem is that they continually expand the bloat. We had physicians complaining about their reimbursement and they board voted to create ANOTHER VP position, this time a VP for "Diversity", whatever that means. Additionally they would create new posititions like "Regional Directors" for small 3 hospital systems that had no such position for 20 years and were some of the most productive and functional in the group.

I'd have more respect for management if they kept costs down and tried to pass on savings to the line docs. Instead they just keep spreading their tentacles and take more and more.

That's the whole point of having a huge empire.

You get to create fluff jobs that have 6 figure salaries and give them to your friends.

This is the business of management. You job is to ensure other people produce results. This job can be done from almost anywhere, it doesn't require lots of effort. What it does require is friends to do it with!

 

[The White Coat Investor]

If you can find a true SDG that's willing to hire you out of residency in a place you want to live with a decent work environment that doesn't require an extended period of indentured servitude then go for it (really, jump on that). But don't sign with what I'll call a quasi-SDG (closed books, only one or a small handful of owners, hx of releasing docs just before making partner, etc) if a true SDG isn't available just because they're not a CMG.

That's good advice.

 

[UnderwaterDoc]

Wow guess the thread got resurrected.

To echo what was said above, CMGs are unavoidable in many parts of the country. I ended up signing up with one because there were no hospitals that were CMG-free in an 100 mile radius from where I wanted to live (trust me I looked). Geography wins for me at least for now.

I ended up not opting for the "firefighter" position. My contract is only a year long and for $200+/hour. Should I not like how things are going at the end of my contract then I will reevaluate my situation. Unfortunately from talking to my classmates who have all been signing contracts in the past few months, there are a lot of popular metropolitan areas that have been swallowed up by CMGs. My guess is that this trend will continue.

 

[@JackShephard]

Wow guess the thread got resurrected.

To echo what was said above, CMGs are unavoidable in many parts of the country. I ended up signing up with one because there were no hospitals that were CMG-free in an 100 mile radius from where I wanted to live (trust me I looked). Geography wins for me at least for now.

I ended up not opting for the "firefighter" position. My contract is only a year long and for $200+/hour. Should I not like how things are going at the end of my contract then I will reevaluate my situation. Unfortunately from talking to my classmates who have all been signing contracts in the past few months, there are a lot of popular metropolitan areas that have been swallowed up by CMGs. My guess is that this trend will continue.

That spells trouble for competition and for physicians in general... Obama's America? Or maybe it's just healthcare was ruined before. Having these large groups skimming off the top of physicians is bad for patients, doctors and hospitals.

 

[Arcan57]

That spells trouble for competition and for physicians in general... Obama's America? Or maybe it's just healthcare was ruined before. Having these large groups skimming off the top of physicians is bad for patients, doctors and hospitals.

It's actually good for hospitals, probably a wash for patients (improved risk management/more accountability due to terminate without cause contracts vs. (alleged) HCA style corporate malfeasance), and neutral/mildly negative for docs. Keep in mind that well-run, reasonable path to partnership SDGs aren't the prevalent model for non-CMG EM contracts in many parts of the country

 

[@JackShephard]

It's actually good for hospitals, probably a wash for patients (improved risk management/more accountability due to terminate without cause contracts vs. (alleged) HCA style corporate malfeasance), and neutral/mildly negative for docs. Keep in mind that well-run, reasonable path to partnership SDGs aren't the prevalent model for non-CMG EM contracts in many parts of the country

It sounds like the government. Bloated, inefficient, cronyism and needless management. These systems make me suspicious.

 

[UnderwaterDoc]

It's actually good for hospitals, probably a wash for patients (improved risk management/more accountability due to terminate without cause contracts vs. (alleged) HCA style corporate malfeasance), and neutral/mildly negative for docs. Keep in mind that well-run, reasonable path to partnership SDGs aren't the prevalent model for non-CMG EM contracts in many parts of the country

This is very true. I have probably heard as much negative chatter on "evil" SDGs as I have on CMGs.

 

[@JackShephard]

The model works like this for some of these groups...

Take 10% from everyone (replace previous group).

Then give 20% increase in pay to a few (firefighters).

Profit.

 

[Arcan57]

The model works like this for some of these groups...

Take 10% from everyone (replace previous group).

Then give 20% increase in pay to a few (firefighters).

Profit.

It depends on what the model was for the group they're replacing in terms of how compensation changes. The main feature of CMG compensation is that they try exceptionally hard to make sure that everyone is paid the same for their clinical work (either on an RVU or hourly basis). Admin work gets a stipend, +/- on nights. Firefighters are a necessary evil for CMGs because they need to be able to staff up quickly to take a new contract but they get phased out as quickly as possible due to the expense (and contrary to Rape of Emergency Medicine, they're not usually the cream of the crop clinically). The main way that CMGs make profit is by flattening out the pay structure so in most cases they're paying above what you'd make as a non-partner but way below what you'd make as a partner. The corporate profits come from the money that would be going to the partners.

 

[EctopicFetus]

It depends on what the model was for the group they're replacing in terms of how compensation changes. The main feature of CMG compensation is that they try exceptionally hard to make sure that everyone is paid the same for their clinical work (either on an RVU or hourly basis). Admin work gets a stipend, +/- on nights. Firefighters are a necessary evil for CMGs because they need to be able to staff up quickly to take a new contract but they get phased out as quickly as possible due to the expense (and contrary to Rape of Emergency Medicine, they're not usually the cream of the crop clinically). The main way that CMGs make profit is by flattening out the pay structure so in most cases they're paying above what you'd make as a non-partner but way below what you'd make as a partner. The corporate profits come from the money that would be going to the partners.

Which is a huge amount of money

 

[Khaos]

I asked that question and got "the look" from those in charge. I asked what "diversity mean". They couldn't give me a defintion, only that this new VP would "Promote Diversity".

I just left that group. I couldn't handle how much they were making off of me anymore. The site I was at was not profitable, thus the new change to an RVU system actually hurt most of the docs at my old site. We get a new interim director that hides the books for the 7 months he was there until we come to find out the group, that isn't profitable, is paying for his luxury condo in downtown, his flights back and forth to see his family, and the pay for him at a higher pay rate than anyone working 4 times more shifts than he is working.

Add the bloat and adding more positions while the individual docs at the old place is losing more money and I couldn't do it anymore. I'm also sure there are going to be others leaving very soon for the same reasons. When the number of docs leaving per year is approaching 10, there is something wrong. I was lied to when I came into the group and realized it about 1 year into it.

I think there has to be a better way to do it than an overhead pushing 40%+

 

[GeneralVeers]

I just left that group. I couldn't handle how much they were making off of me anymore. The site I was at was not profitable, thus the new change to an RVU system actually hurt most of the docs at my old site. We get a new interim director that hides the books for the 7 months he was there until we come to find out the group, that isn't profitable, is paying for his luxury condo in downtown, his flights back and forth to see his family, and the pay for him at a higher pay rate than anyone working 4 times more shifts than he is working.

Add the bloat and adding more positions while the individual docs at the old place is losing more money and I couldn't do it anymore. I'm also sure there are going to be others leaving very soon for the same reasons. When the number of docs leaving per year is approaching 10, there is something wrong. I was lied to when I came into the group and realized it about 1 year into it.

I think there has to be a better way to do it than an overhead pushing 40%+

High turnover is their expectation. Have you ever wondered why they spend so much time, effort, and money on recruiting? The company isn't expanding that quickly, but there is constant turnover of talent, especially at the less-profitable and lower-paying sites. They go out of their way to recruit from residencies (hence new grads who don't understand the game) by throwing fancy parties (costing upwards of $30,000), recruitment dinners, and giving out lots of swag. Once the new docs start working, they typically last 1-2 years before moving on to greener pastures. Rinse and repeat.

 

[golghiapparatus]

Im with whitecoat.. i work for an sdg, our overhead is under 15%. IMO even in a "bad payer" place the doc should be pulling in $200/hr. The number I have heard from the heads of the CMGs is "about 30%" for overhead. Remember all those suits need to make their money. That money is coming right off your back. On top of that they need to generate profit.

Just curious, since managers are a dime a dozen and proliferate like Y. pestis in 13th century England: why not just turn the model upside down and have SDGs hire managers as needed to maximize efficiency? Let the manager manage the things needing managing and let the docs see patients...

 

[EctopicFetus]

Just curious, since managers are a dime a dozen and proliferate like Y. pestis in 13th century England: why not just turn the model upside down and have SDGs hire managers as needed to maximize efficiency? Let the manager manage the things needing managing and let the docs see patients...

SDGs hire people to help. The question is who "OWNS" the relationship between the ED and the hospital. IMO when it is a manager it is a CMG. When its a single physician then IMO its not much better. a TRUE SDG you have a powerful thing. You have all (or almost all) of the physicians engaged. The manager is only there to support the partners.

 

[Arcan57]

SDGs hire people to help. The question is who "OWNS" the relationship between the ED and the hospital. IMO when it is a manager it is a CMG. When its a single physician then IMO its not much better. a TRUE SDG you have a powerful thing. You have all (or almost all) of the physicians engaged. The manager is only there to support the partners.

Do you worry that it's going to be difficult to find docs willing to commit to EM as a career? Because that seems to be a prerequisite for the group to stay successful. If your docs just want to punch the clock until they can get their monthly week long out of state vacation, that contract is going bye-bye.

 

[EvoDevo]

I interviewed with a truly Democratic sdg in VA and it was awesome. Unfortunately my spouse wasn't willing to make VA a reality. Now in Texas and have noticed that CMGs seem to be the standard

 

[TrumpetDoc]

I am a new partner in a SDG now. Was a member of a CMG before. They lost their contracts and poof...
I licked out as the timing was right.
The deal is SSOOOOOOOOOOOOOO Much better in a SDG IF you get one that is straight up, not shady, short initiation, and open.

There are a bunch that give them a bad name.

It is very unfortunate that the SDG is an endangered species. Mostly because of hospitals and what CMGs claim to promise.
However, I see even the CMGs going away as hospitals go for total control/ employment if the docs.

 

[EctopicFetus]

Do you worry that it's going to be difficult to find docs willing to commit to EM as a career? Because that seems to be a prerequisite for the group to stay successful. If your docs just want to punch the clock until they can get their monthly week long out of state vacation, that contract is going bye-bye.

NO worries at all. I have been here for almost 5 years. We have 40 docs, 3 left all for non clinical careers. After me we hired 4 more. no one is leaving. IMO you have to recruit appropriately. If you do this your retention remains high, people stay involved. Excellent pay is key IMO.

If you interviewed here and we believed you wanted to punch the clock and not be involved you would quickly be dismissed in the interview process. Of the last 14 hires (last 7 years) all have been involved in some way.

Since we have had the contract for 30+ years I feel ok. The truth is we are constantly working on getting better. Thats a requirement too. We know the CMGs want us, we know they flirt with our hospital system. We do the same and so far we have been better at it. Its like a marriage, it doesnt end on your wedding day you have to keep working.

 

[Hercules]

NO worries at all. I have been here for almost 5 years. We have 40 docs, 3 left all for non clinical careers. After me we hired 4 more. no one is leaving. IMO you have to recruit appropriately. If you do this your retention remains high, people stay involved. Excellent pay is key IMO.

If you interviewed here and we believed you wanted to punch the clock and not be involved you would quickly be dismissed in the interview process. Of the last 14 hires (last 7 years) all have been involved in some way.

Since we have had the contract for 30+ years I feel ok. The truth is we are constantly working on getting better. Thats a requirement too. We know the CMGs want us, we know they flirt with our hospital system. We do the same and so far we have been better at it. Its like a marriage, it doesnt end on your wedding day you have to keep working.

All very good points. We are very selective in out interviews and have been willing to work short handed for a few months at times if the right applicant isn't there. We haven't had anyone leave for another EM job in more than 20 years. I think SDGs are definitely not for everyone though. Several of my classmates are very happy punching the clock with their CMGs and would be miserable in my SDG group.

 

[EctopicFetus]

All very good points. We are very selective in out interviews and have been willing to work short handed for a few months at times if the right applicant isn't there. We haven't had anyone leave for another EM job in more than 20 years. I think SDGs are definitely not for everyone though. Several of my classmates are very happy punching the clock with their CMGs and would be miserable in my SDG group.

I agree. the CMGs of the world are right for some people. We dont have part time, you dont just come and work 3 shifts a month. Its a commitment to being an owner and with that certainly an unwritten promise of your time and for that great financial gain. To me it is simply worth it. I could work much less, earn more and have SOME control over my work environment.

 

[The White Coat Investor]

If you want a CMG-style job, at least go with one that is like a big SDG- i.e. owned by you. EMP for example. Be an owner.

 

[GeneralVeers]

If you want a CMG-style job, at least go with one that is like a big SDG- i.e. owned by you. EMP for example. Be an owner.

You are NOT an owner with EMP. Although they claim it is "physician owned" and refer to all of the physicians as owners, it is simply an employment contract with equity that is paid out when you leave the company. You can be fired just like any other employee, and the company can take your "share" if they fire you for cause. You can't stop working clinically and still "own" a piece of the company. The share that you are supposedly given after working a given period of time is not your property and you have no legal claim to it beyond what they pay you out once you leave the company.

 

[The White Coat Investor]

You are NOT an owner with EMP. Although they claim it is "physician owned" and refer to all of the physicians as owners, it is simply an employment contract with equity that is paid out when you leave the company. You can be fired just like any other employee, and the company can take your "share" if they fire you for cause. You can't stop working clinically and still "own" a piece of the company. The share that you are supposedly given after working a given period of time is not your property and you have no legal claim to it beyond what they pay you out once you leave the company.

Who's the owner then?

 

[GeneralVeers]

Who's the owner then?

The contracts are owned by the LLC, which is run by the guys who founded the company. The truth is, that after physician salary is paid, there isn't much money left over. The real money goes to the holdings company that contracts with the medical group for billing, coding, HR, malpractice, and health insurance. That holdings company has shares that are majority-owned by 5-6 people who in the past have made a fortune off of selling services to the medical group. The average doctor in the group does not get shares of the holdings company, however you have the option to purchase stock if you want to.

 

[The White Coat Investor]

The contracts are owned by the LLC, which is run by the guys who founded the company. The truth is, that after physician salary is paid, there isn't much money left over. The real money goes to the holdings company that contracts with the medical group for billing, coding, HR, malpractice, and health insurance. That holdings company has shares that are majority-owned by 5-6 people who in the past have made a fortune off of selling services to the medical group. The average doctor in the group does not get shares of the holdings company, however you have the option to purchase stock if you want to.

Sooo.....you can be an owner if you want to but most choose not to? Sounds like a personal problem.

I mean, after physician salary is paid, there isn't any money left over in the SDG I work for. If we make more, the salary is higher. If we make less, the salary is lower. The point of the business is to maximize the physician salary.

I also buy shares in the holding company that owns our business office and contracts with our group. Some doctors in the group choose not to. Their loss.

 

[EctopicFetus]

I tend to agree with Veers. EMP isnt an SDG. They simply pitch this cause it sounds good. I know it cant/wont happen but these CMG models are bad for us. EM brought this upon ourselves and the future isnt bright IMO. At this point we are playing with house money. To my colleagues who went to work for CMGs I am sorry for you. Whats saddest is that many dont have any idea just how much money they are making for others.

 

[GeneralVeers]

Sooo.....you can be an owner if you want to but most choose not to? Sounds like a personal problem.

Most do not buy stock. If you do choose to buy stock (which I did), you own a part of the holdings company that manages the billing/coding. It used to pay out about 7% annual dividend, though that has dropped dramatically last year. More important though is that you are NEVER an owner in the medical group itself, despite their false advertising to the contrary.

I mean, after physician salary is paid, there isn't any money left over in the SDG I work for. If we make more, the salary is higher. If we make less, the salary is lower. The point of the business is to maximize the physician salary.

Exactly what most groups do. Any group that isn't paying out net collections every month entirely in salary is being dishonest.

 

[two guys]

I tend to agree with Veers. EMP isnt an SDG. They simply pitch this cause it sounds good. I know it cant/wont happen but these CMG models are bad for us. EM brought this upon ourselves and the future isnt bright IMO. At this point we are playing with house money. To my colleagues who went to work for CMGs I am sorry for you. Whats saddest is that many dont have any idea just how much money they are making for others.

This is frequently said on here. I think it's probably true, but its darn near impossible to prove. I'd love to know, what you think people working for a cmg are making for others (vs SDG)?

Common sense says that the CMGs must be taking some of our money. They have all those VPs and parties and pay for recruiting and firefighters. Of course, they'll tell you that they bill more efficiently and have the benefit of the economy of scale - both of these are probably true to some extent. That being said, the big CMGs make billion dollar profits yearly. Divided amongst the # of physician it might not be more than 10k, but it sure adds up.

I'm in my second job. I've looked at a bunch of jobs in the SE with different CMGs and a few SDGs. The best I can tell, the pay was close to the same. The CMGs start out much higher but never increase over your career. The SDGs start out lower but all increase over your career, some more dramatically than others. I always asked what the partner bonus was and it is hard to predict but it doesn't seem like there was >50k difference between the sdg and pdg over a 10 year period.

I could easily figure out what % of my pay is being taken if I knew the RVU reimbursement at my facility. I'd just subtract it from my rvu pay and that would be overhead plus cmg profit. Too bad I'll never get a cmg to tell me that. I'd love to hear what the average rvu reimbursement was for a similar facility (and even started a thread to try to figure it out) but haven't gotten any takers.

I always planned on working for a democratic group but they don't exist here. I really struggled to take my first cmg job over what I thought of them. Now, I'm not sure they are as evil as I thought. Maybe I'm just drinking the kool-aid, but it seems like I make similar $ as my peers who live in places with democratic groups. I've got a little less say so in things, but I'm still involved in committees and good citizen type of stuff. I don't really like how productivity and profit driven the arrangement is, but I imagine these realities are probably true at democratic groups as well.

 

[GeneralVeers]

It's not that hard to figure out how much the group collects on your behalf. Most of the larger "democratic" CMGS should have data on billing/collections at individual sites. If your site collects on average $120 per patient visit, and you see 2.0 pts per hour, then on average they collect $240/hour. The difference between that number, and your gross salary is the overhead that the are taking. On average your benefits, including malpractice, health insurance, retirement, etc should cost around $25/hour.

 

[Janders]

Open books make it easy to see how much of your hard labor is being skimmed off, and exactly what that skimming is going to. Malpractice? CME allowance? Good billing company? All probably good expenses. 14 different VPs who don't work clinically? Likely not what you want to be paying for.

Theoretically, a CMG could easily pay an individual doc as much as a SDG. Heck, maybe they COULD do better due to economy of scale, by lowering overhead a percentage or two. If this was true, I'd expect them to open their books and prove it (and trumpet it...).

I like being able to see where every penny billed under my name goes...

Of note, I've worked as a hospital system employee (salaried, basically). This job still gave me a report of my billings and collections every month!

 

[Joriel]

I like being able to see where every penny billed under my name goes...

Of note, I've worked as a hospital system employee (salaried, basically). This job still gave me a report of my billings and collections every month!

In my experience, working as a hospital employee is fairly similar to working for a CMG. I have NEVER received a report of my billings and collections, the medical group/people on high set the hourly rate, the site medical director determines the bonus criterion every quarter without any input from the pit docs, and there is a whole team of VPs/suits that get payed a ton w/o working clinically.

In some ways the hospital employee model is a more frightening scenario than the corporate groups. They are increasing in number (in part due to the ACA), it is less common to have an EM person in the leadership (incredibly rare to have more than one), the benefits are often less EM specific, and you can still be told how to practice medicine.

 

[EctopicFetus]

I looked into this and from speaking to some people I know the CMGs take 28-30%. My SDG takes under 15%. The difference is not just that which probably amounts to 40k per yr but also your say in the group. Our group is aggresive in our contracting which makes an even bigger difference. Also, keep in mind my PAs make me money, the CMG PAs are all work and no profit for those docs.

On top of that i make money off the buyin of the younger partners.

 

[GeneralVeers]

The thing I like about being a hospital employee is that the hospital can run the ED at a loss. They can offer wages higher than a CMG in order to attract physicians to an undesirable area. A CMG in general will not offer pay more than what they collect.