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This is a long read, but I hope well worth the time it will take. For the average physician who grinds it out every day, and comes home exhausted from running to make metrics and satisfaction scores, this is a must read. As we go along in this thread, I'll give additional follow-ups and track the progress of a small democratic group as it goes from start-up, to growth, to buyout, to CMG affiliate...
After reading several posts about CMG acquisitions, SDG buyouts, and ranting and raving about hourly rates, it is surprising to me how little we as emergency physicians truly know about our revenue and how our incomes are derived. More worrisome, is how much we are truly being taken advantage of.
What you are about to read is not confidential, but true. My background as an employee, medical director, and managing partner in a "CMG" should suffice as one who truly knows the big picture of emergency medicine economics. If you are going to post about your hourly rate, bicker about $20-30 or $100 per hour differences in regional pay, or expound upon the virtues and rewards of locums work, please don't do so here. This is a true thread about the REAL profit and loss of emergency practice. The actual nuts and bolts that you will not know unless you are the one writing the check for the doctors and owners in your group.
First, if you are the owner, CEO, President, or Managing Partner of a CMG and you follow this website, please make your presence known and provide your input. Seriously. The floor is yours. Having been a member of this board for 12 years and counting, your input is welcome. Since the vast majority of the members on this board are pit docs, new attendings, or residents, I'm willing to bet this call out will go unanswered, but truly hope you chime in. For the rest of you who read this, please learn from it and soak in the details. This is your income, livelihood, and the future of your speciality.
To begin, there is really only one number that you need to know. $150. That's right, $150. This is the average amount of money COLLECTED per patient across the board, across the country. Not billed, not in accounts receivable, not cash only, ACROSS THE BOARD for ALL PATIENTS. Remember this number. This is after 1/3 of your patients (self pay) don't ever pay you, 1/3 of your medicare and medicaid patients pay you at reduced rates, and 1/3 of those with private insurance pay you what they decide to pay you. Payor mix (the ratio of these three components) may vary from place to place, but $150 averaged per patient is fairly reliable.
The average emergency physician works around 1400 hours per year, and sees around 2 patients per hour. Some work more, some work less. Some are faster, some slower. In addition, the average physician that supervises midlevel providers may see an additional 1 patient per hour depending on volume or staffing. None of these numbers matter in this example. None of the scheduling patterns matter for the first part of this thread. The only thing that matters is the volume of patients you see at your facility. Period. If you don't know how many patients you see at your facility, you don't know how "fair" your pay is. In reality, your pay is so unfairly low that the word "fair" should not be mentioned in this thread either.
A small emergency department that sees 15,000 patients annually is a contract worth $2,250,000 annually. a large emergency department that sees 100,000 patients annually is a contract worth $15,000,000 annually. For basic math, every 10,000 patients seen in a department is worth $1,500,000 of revenue.
Lets use an average community hospital and a small democratic group (SDG) as an example for EMGA - Emergency Medicine Group A - a fictitious company used to demonstrate where money flows. EMGA staffs a hospital that sees 40,000 visit annually and has a gross operating income of $6,000,000. The hospital is a local community hospital, not for profit, and has been serving the community for over 40 years. The group owners grew up in the community and know the CEO personally. The community has an average income demographic, and the hospital enjoys annual community donations to its programs for growth and expansion.
The group took out a loan for $1,000,000 to open its doors, buy office equipment and furniture, hire staff, and cover physician salary for 4 months until billed accounts receivable began to come in. Also, as is common practice, the group asked the hospital to partner with them as a business, and were given a $1,000,000 annual stipend as part of their contract.
Since ED staffing models are fairly uniform, and follow a common hourly distribution nationwide, the group decides to staff 5 physicians daily, with overlapping shifts during the peak hours of the day, and single coverage at night. Coverage in this example is not related to income or profit margin, but simply a model chosen by the group members to provide a "lifestyle" instead of a maximized profit. In order to accommodate each provider working 1/2 of the month (15 shifts), the group hires 10 physicians to staff their model. These 10 physicians have become the first units of overhead for the group. They are paid as 1099 independent contractors. For ease of tracking, I will leave the remaining profit margin as a header below between paragraphs. Assuming 10 physicians are each earning an annual salary of $300,000, their overhead to the practice is $3M, or 50% of the gross operating margin of the group.
$3,000,000
Where does the remaining $3M in profit go?
Malpractice insurance varies by provider and group policy, but as a rough number, is around $25,000 per provider per year. It costs $250,000 annually to insure 10 physicians.
$2,750,000
Taking away the biggest cost to operate EMGA, there is a remaining operating budget of $2.75M. Billing and Coding is an additional cost most groups spend. Outsourcing your billing and coding provides a layer of protection between payers and providers, and holds another entity accountable for investigation such as fraudulent billing, claim denials, etc. These rates can vary, but are typically 2% per chart, or 2% of the gross operating budget ($120,000). Lets deduct this from our gross profit.
$2,630,000
EMGA has adopted a lean operating model, and uses hospital EMR and IT for charting. Medical Records are held by the hospital and billing records are kept by the coding company. They have hired an insurance adjuster to ensure regular collections are provided and to fight claim denials with the billing company and patient insurance carriers. The annual salary for this position is $85,000. In addition, the company provides health insurance, holiday pay, and other basic benefits including a 401(k) match for this employee worth an additional $10,000 annually, making the total cost of this employee $95,000. The group has also hired one of their providers to serve as a medical director. Her role is to interface with the hospital, attend critical hospital meetings, meet with hospital administration, perform data analysis for the group's quality metrics, provide feedback to physicians, and run monthly department meetings to communicate hospital needs and manage physician needs with the hospital. The Medical Director has opted to receive a stipend as part of her 1099 income, and will not be paid benefits. This costs the group $200,000. The Medical Director will also pick up shifts at salaried rate. Finally, the final component of the lean operating model is to hire an administrative assistant, who serves as the contact for the group, secretary, and scheduler for the physicians. This cost including benefits is $55,000 per year. The total employee/salary cost for EMGA is $350,000.
$2,280,000
Finally, the group has decided to rent an office for its employees, and also has regular ongoing costs to operate (accountant, lawyer, copier, maintenance, coffee, paper, computers and IT service, etc). These are lumped together as general and administrative expenses (G&A), and cost around $125,000 per year. In addition, the group devised a 10-year repayment plan for its startup loan, and will spend an additional $110,000 annually to repay their bank.
$2,045,000
After everyone as been paid, overhead has been met, and all of the bills are satisfied, EMGA has a gross profit of $2,045,000. In addition, the group had negotiated a stipend from the hospital, and receives $1,000,000 annually based on patient volume, and tied to metrics and satisfaction. The hospital made good on their payment to the group this year, adding to the group's income.
$3,045,000
Where does the rest of this money go? Over 50% of the total group income is left over annually. The group structured their business as an LLC, which has some business and provider protection, and also has a relative tax obligation. The physicians opted to create an annual bonus pool to share equally as partners at the end of the year, and have their accountant determine the most effective tax structure for that year before they distribute their bonuses. This year, the accountant determined that the group would need to pay 27% of its profit as taxes (including the payroll taxes for the office staff). This left $2,222,850 to share between the 10 doctors. The physicians opted to leave $250,000 in an interest-bearing management account to accommodate for tax changes or unexpected expenses, and divided the remaining amount between themselves, each taking a bonus of ($2,222,850 - $250,000)/10 or $197,285.00 for the year.
Each physician in the group earned a base salary of $300,000 and bonused $197,285, for a total equal partner compensation of $497,285.00. This means that after taxes, loan payments, salaries, benefits, and all business overhead, physician salaries were 83% of the group's gross income, and their average combined clinical and partnership hourly rate was $355.20/hr.
This is a fairly typical example of how a true democratic group is structured. There are some variations, such as designating certain members of the group to hold additional duties such as group president, treasurer, etc, which may reduce overhead by a small margin, and also change the ratio that partners are bonused (i.e. president may take 20%, treasurer may take 15%, etc). The take home point is that the overall dollar amount to share remains the same, the group, minus the $250,000 is places into a reserve fund, runs a zero balance at the end of its fiscal year
What happens over the next few years will blow your mind...
After reading several posts about CMG acquisitions, SDG buyouts, and ranting and raving about hourly rates, it is surprising to me how little we as emergency physicians truly know about our revenue and how our incomes are derived. More worrisome, is how much we are truly being taken advantage of.
What you are about to read is not confidential, but true. My background as an employee, medical director, and managing partner in a "CMG" should suffice as one who truly knows the big picture of emergency medicine economics. If you are going to post about your hourly rate, bicker about $20-30 or $100 per hour differences in regional pay, or expound upon the virtues and rewards of locums work, please don't do so here. This is a true thread about the REAL profit and loss of emergency practice. The actual nuts and bolts that you will not know unless you are the one writing the check for the doctors and owners in your group.
First, if you are the owner, CEO, President, or Managing Partner of a CMG and you follow this website, please make your presence known and provide your input. Seriously. The floor is yours. Having been a member of this board for 12 years and counting, your input is welcome. Since the vast majority of the members on this board are pit docs, new attendings, or residents, I'm willing to bet this call out will go unanswered, but truly hope you chime in. For the rest of you who read this, please learn from it and soak in the details. This is your income, livelihood, and the future of your speciality.
To begin, there is really only one number that you need to know. $150. That's right, $150. This is the average amount of money COLLECTED per patient across the board, across the country. Not billed, not in accounts receivable, not cash only, ACROSS THE BOARD for ALL PATIENTS. Remember this number. This is after 1/3 of your patients (self pay) don't ever pay you, 1/3 of your medicare and medicaid patients pay you at reduced rates, and 1/3 of those with private insurance pay you what they decide to pay you. Payor mix (the ratio of these three components) may vary from place to place, but $150 averaged per patient is fairly reliable.
The average emergency physician works around 1400 hours per year, and sees around 2 patients per hour. Some work more, some work less. Some are faster, some slower. In addition, the average physician that supervises midlevel providers may see an additional 1 patient per hour depending on volume or staffing. None of these numbers matter in this example. None of the scheduling patterns matter for the first part of this thread. The only thing that matters is the volume of patients you see at your facility. Period. If you don't know how many patients you see at your facility, you don't know how "fair" your pay is. In reality, your pay is so unfairly low that the word "fair" should not be mentioned in this thread either.
A small emergency department that sees 15,000 patients annually is a contract worth $2,250,000 annually. a large emergency department that sees 100,000 patients annually is a contract worth $15,000,000 annually. For basic math, every 10,000 patients seen in a department is worth $1,500,000 of revenue.
Lets use an average community hospital and a small democratic group (SDG) as an example for EMGA - Emergency Medicine Group A - a fictitious company used to demonstrate where money flows. EMGA staffs a hospital that sees 40,000 visit annually and has a gross operating income of $6,000,000. The hospital is a local community hospital, not for profit, and has been serving the community for over 40 years. The group owners grew up in the community and know the CEO personally. The community has an average income demographic, and the hospital enjoys annual community donations to its programs for growth and expansion.
The group took out a loan for $1,000,000 to open its doors, buy office equipment and furniture, hire staff, and cover physician salary for 4 months until billed accounts receivable began to come in. Also, as is common practice, the group asked the hospital to partner with them as a business, and were given a $1,000,000 annual stipend as part of their contract.
Since ED staffing models are fairly uniform, and follow a common hourly distribution nationwide, the group decides to staff 5 physicians daily, with overlapping shifts during the peak hours of the day, and single coverage at night. Coverage in this example is not related to income or profit margin, but simply a model chosen by the group members to provide a "lifestyle" instead of a maximized profit. In order to accommodate each provider working 1/2 of the month (15 shifts), the group hires 10 physicians to staff their model. These 10 physicians have become the first units of overhead for the group. They are paid as 1099 independent contractors. For ease of tracking, I will leave the remaining profit margin as a header below between paragraphs. Assuming 10 physicians are each earning an annual salary of $300,000, their overhead to the practice is $3M, or 50% of the gross operating margin of the group.
$3,000,000
Where does the remaining $3M in profit go?
Malpractice insurance varies by provider and group policy, but as a rough number, is around $25,000 per provider per year. It costs $250,000 annually to insure 10 physicians.
$2,750,000
Taking away the biggest cost to operate EMGA, there is a remaining operating budget of $2.75M. Billing and Coding is an additional cost most groups spend. Outsourcing your billing and coding provides a layer of protection between payers and providers, and holds another entity accountable for investigation such as fraudulent billing, claim denials, etc. These rates can vary, but are typically 2% per chart, or 2% of the gross operating budget ($120,000). Lets deduct this from our gross profit.
$2,630,000
EMGA has adopted a lean operating model, and uses hospital EMR and IT for charting. Medical Records are held by the hospital and billing records are kept by the coding company. They have hired an insurance adjuster to ensure regular collections are provided and to fight claim denials with the billing company and patient insurance carriers. The annual salary for this position is $85,000. In addition, the company provides health insurance, holiday pay, and other basic benefits including a 401(k) match for this employee worth an additional $10,000 annually, making the total cost of this employee $95,000. The group has also hired one of their providers to serve as a medical director. Her role is to interface with the hospital, attend critical hospital meetings, meet with hospital administration, perform data analysis for the group's quality metrics, provide feedback to physicians, and run monthly department meetings to communicate hospital needs and manage physician needs with the hospital. The Medical Director has opted to receive a stipend as part of her 1099 income, and will not be paid benefits. This costs the group $200,000. The Medical Director will also pick up shifts at salaried rate. Finally, the final component of the lean operating model is to hire an administrative assistant, who serves as the contact for the group, secretary, and scheduler for the physicians. This cost including benefits is $55,000 per year. The total employee/salary cost for EMGA is $350,000.
$2,280,000
Finally, the group has decided to rent an office for its employees, and also has regular ongoing costs to operate (accountant, lawyer, copier, maintenance, coffee, paper, computers and IT service, etc). These are lumped together as general and administrative expenses (G&A), and cost around $125,000 per year. In addition, the group devised a 10-year repayment plan for its startup loan, and will spend an additional $110,000 annually to repay their bank.
$2,045,000
After everyone as been paid, overhead has been met, and all of the bills are satisfied, EMGA has a gross profit of $2,045,000. In addition, the group had negotiated a stipend from the hospital, and receives $1,000,000 annually based on patient volume, and tied to metrics and satisfaction. The hospital made good on their payment to the group this year, adding to the group's income.
$3,045,000
Where does the rest of this money go? Over 50% of the total group income is left over annually. The group structured their business as an LLC, which has some business and provider protection, and also has a relative tax obligation. The physicians opted to create an annual bonus pool to share equally as partners at the end of the year, and have their accountant determine the most effective tax structure for that year before they distribute their bonuses. This year, the accountant determined that the group would need to pay 27% of its profit as taxes (including the payroll taxes for the office staff). This left $2,222,850 to share between the 10 doctors. The physicians opted to leave $250,000 in an interest-bearing management account to accommodate for tax changes or unexpected expenses, and divided the remaining amount between themselves, each taking a bonus of ($2,222,850 - $250,000)/10 or $197,285.00 for the year.
Each physician in the group earned a base salary of $300,000 and bonused $197,285, for a total equal partner compensation of $497,285.00. This means that after taxes, loan payments, salaries, benefits, and all business overhead, physician salaries were 83% of the group's gross income, and their average combined clinical and partnership hourly rate was $355.20/hr.
This is a fairly typical example of how a true democratic group is structured. There are some variations, such as designating certain members of the group to hold additional duties such as group president, treasurer, etc, which may reduce overhead by a small margin, and also change the ratio that partners are bonused (i.e. president may take 20%, treasurer may take 15%, etc). The take home point is that the overall dollar amount to share remains the same, the group, minus the $250,000 is places into a reserve fund, runs a zero balance at the end of its fiscal year
What happens over the next few years will blow your mind...
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