Is EM really that competitive?

[charmiedermie]

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You may oppose universal healthcare on philosophical or practical grounds, but my point that people are not denied emergency care in civilized parts of the world stands valid.
I see that people are complaining of having to treat patients that won't pay for their services, well I have suggested a solution to that - universal healthcare coverage. Whether that would drop how much ER physicians make I don't know, but last time I checked physicians in Canada were doing well even though that is exactly the system that they have. But what's the alternative - denying people emergency care altogether?

Will believe all of this when you freely take universal single payer insurance for all your patients. I think it is criminal that citizens have to bear continued tooth and mouth pain, unable to talk, unable to consume food and drink, and you deny people emergency tooth care.

under the poster's location, it says "moral high" HAHA

Hard to tell if it's a location or a state of being.

 

[zero0]

You may oppose universal healthcare on philosophical or practical grounds, but my point that people are not denied emergency care in civilized parts of the world stands valid.
I see that people are complaining of having to treat patients that won't pay for their services, well I have suggested a solution to that - universal healthcare coverage. Whether that would drop how much ER physicians make I don't know, but last time I checked physicians in Canada were doing well even though that is exactly the system that they have. But what's the alternative - denying people emergency care altogether?

No one is denied emergency care in the US. It is against the law. As EPs, our contention isn't that we have to see certain pts, it is that we have to take on all of the liability without a equitable system for compensation for that risk.

Your suggestion for universal healthcare coverage won't make this situation better in this specific context because there is already a mandate for universal emergency care; the problem is that this mandate is not funded and new there is new legislation that may just make things worse, not better.

pimp'd

 

[Dires]

Hate to break it to anyone, but not being able to receive emergency care when such care is available is absolutely unprecedented anywhere in the world.

You may oppose universal healthcare on philosophical or practical grounds, but my point that people are not denied emergency care in civilized parts of the world stands valid.

I get all giddy inside when the sacrificial lambs get caught in their own pile of bull****.

 

[sylvanthus]

Can somebody remind me why EM is so desirable these days?

I say this as an EM resident currently - by the time that you medical students are done with your EM residencies I don't believe the getting will be good. A big reason EM has hit a boom is because of the way our health system has fallen into place. There's a dearth of primary care docs/PAs/NPs/whatever and a relatively new glut of insured patients. This is a very simplified view of something way more complex, but you get the pic. Thus urgent cares and EDs are cleaning up.

The second that this changes, all the "wide-open" job markets you hear about will close tightly again.

And that doesn't even consider the actual day-to-day practice of EM. Generally some single digit percentage of my patients on any given day are TRUE emergencies. Otherwise it's a glorified and expensive family medicine clinic.

Add a few drunks, homeless, and entitled poor (not saying all of the needy are entitled, but interestingly a large percentage of the ones that I treat are far more entitled than the "richies), and boom you have a huge recipe for becoming jaded towards your fellow man, burnt out on your job, and chronically ill (poor health habits and self care).

Now add the constantly changing schedule, and you begin to wonder why this field is DESIRABLE...

All of this for what? A salary of 200k/year to be a replaceable cog in the corporate EM world?

Yet at the end of the day, I really love it. No joke, I just do everything I can to make sure medical students really truly know what they're getting themselves into.

And yes, I dabbled in derm, plastics, ortho for a while (I had the board scores, name brand school, etc), and I honestly think those specialties are popular PURELY because of their reimbursement potential. Nothing more.

You're hearing the wrong information if you think EM makes 200k/year.

 

[Makati2008]

You're hearing the wrong information if you think EM makes 200k/year.

Long time no see. I think he is meaning down the line.

 

[exsanguination]

Long time no see. I think he is meaning down the line.

Yea, I think within 3-4 years the EM heyday will be over and we can expect salaries closer to 175-200k/year. There's no way the system can continue as it is, and looking at current legislation (balanced billing any one?), the downward pressure on EMTALA bound physicians' salaries will continue until it becomes a matter of large-scale life/death or access.

 

[exsanguination]

The "tl;dr" version for the medical students reading this is very clear:

DO NOT GO INTO EMERGENCY MEDICINE IF MONEY MEANS SOMETHING TO YOU

If you have loads of debt, if you have desires for a large house and fancy car, or you plan to get divorced a few times, I'd stick with the surgical subspecialties or cash-based specialties. However, like telling a morbidly obese patient to lose weight, the IDEA is simple, but the path is difficult. Not everybody can match into derm, ortho, ENT, etc...

CHOOSE YOUR SPECIALTY WISELY

 

[kenjixshadow]

Yea, I think within 3-4 years the EM heyday will be over and we can expect salaries closer to 175-200k/year. There's no way the system can continue as it is, and looking at current legislation (balanced billing any one?), the downward pressure on EMTALA bound physicians' salaries will continue until it becomes a matter of large-scale life/death or access.

That's insanely bad. Do you think EPs would still work for that much pay cut or walk or do a fellowship? I mean heck, even working in urgent care or as hospitalist can pull more than that.

 

[asdf123g]

That's insanely bad. Do you think EPs would still work for that much pay cut or walk or do a fellowship? I mean heck, even working in urgent care or as hospitalist can pull more than that.

Im not in the field but i'd imagine no, most would not work for that much (early retirement?) and EM would plummet in competitiveness with it. It'd be pretty awful to complete a residency only to be forced to spend an extra 2-3 years working on a fellowship to maybe make as much as before.

 

[exsanguination]

That's insanely bad. Do you think EPs would still work for that much pay cut or walk or do a fellowship? I mean heck, even working in urgent care or as hospitalist can pull more than that.

The same thing will happen to hospitalists too. Any large multi-state contract management group (CMG) or hospital-based physician will end up facing these downward salary pressures. Urgent cares, outpatient clinics... they will all face the same result.

Go ahead and ask any hospitalist at your institution about what's happening to their reimbursement.

Hospitalists and EM docs are similar in this regard and will face many of the same challenges.

As for whether physicians will walk.. that depends. I think most doctors will continue to work. Look at the previous 2-3 decades. The doctors in the golden 80s and 90s, you know the FM docs that were pulling a mil/year back then, continued to work throughout the worsening reimbursement rates towards the late 90s that continue today.

How many docs do you know that reluctantly trudge onwards despite continuously complaining about decreasing reimbursement? I know quite a few. At the end of the day you need money to pay for your kids' college, your mortgage, your divorce alimony/child support, your loans, your inflating lifestyle etc etc etc.

I think fellowship will come more popular sure, but there are very few EM fellowships that INCREASE ones salary. The only ones I can think of really are POTENTIALLY pain medicine and critical care. Otherwise every other EM fellowship potentially results in a decrease (there are no tox jobs out there, US doesn't pay more just allows you to work less, EMS same thing as US, admin same thing as US. Tactical medicine, wilderness medicine, simulation, and other fringe non-accredited fellowships also don't pay. I forget whether these are accredited or not actually, but the point remains).

The key to financial freedom in medicine is simple. There are TWO ROUTES:

1. Non-surgical subspecialty and non-cash-based specialty: be frugal, live like a resident, invest wisely and you can live with your 200k/year salary

2. Pursue a surgical subspecialty or cash based specialty. Ball out as desired. FYI this category includes things like interventional cards and other specialized procedure based specialties.

 

[exsanguination]

Im not in the field but i'd imagine no, most would not work for that much (early retirement?) and EM would plummet in competitiveness with it. It'd be pretty awful to complete a residency only to be forced to spend an extra 2-3 years working on a fellowship to maybe make as much as before.

Indeed competitiveness would plummet, and that's what I predict for EM at the end of 5-7 years. We saw it with anesthesia, and EM's pendulum is swinging.

I think you'll see a flood of foreign graduates rounding out the spots if the salary ever dips below 200k/year. You're right, the job itself is way too stressful, high risk, and thankless for high performing american graduates to ever consider if the salary dips.

 

[TBV]

I wanna take advice on the future of EM salary from here but I just can't. I recall reading years ago posters going on and on about orthos taking hits and spinal ortho being the first to fall from it's glorious peak... Fast forward and they haven't proven the SDN gloom and doom crowd right yet.

 

[exsanguination]

I wanna take advice on the future of EM salary from here but I just can't. I recall reading years ago posters going on and on about orthos taking hits and spinal ortho being the first to fall from it's glorious peak... Fast forward and they haven't proven the SDN gloom and doom crowd right yet.

If you can't see the difference between an ELECTIVE PROCEDURAL SPECIALTY and a specialty where you are MANDATED BY LAW (EMTALA) to see all patients REGARDLESS OF ABILITY TO PAY, then you are truly in need of SERIOUS education.

I urge all medical students to learn how their desired specialty is reimbursed.

Orthopaedics has always been compensated well. It will continue to be compensated well. You are paid PER PROCEDURE. There is no law FORCING you to operate on everything that presents at your surgical center or clinic thus you will always be able to command a price per patient.

Even when bundled payments are fully rolled out (an effort by the ACA to curb fee for service), elective surgical specialists and fancy IM proceduralists will still be reimbursed well. They will still get that bundled amount for that entire healthcare event. They will just become smarter and more efficient regarding how to use that money in order to maintain the same margin. Additionally, these subspecialties are driven by device companies who are always upgrading, adding bells and whistles, and seeking to drive profits as well. Rest assured they will together find a way to pull money from the system.

 

[TBV]

If you can't see the difference between an ELECTIVE PROCEDURAL SPECIALTY and a specialty where you are MANDATED BY LAW (EMTALA) to see all patients REGARDLESS OF ABILITY TO PAY, then you are truly in need of SERIOUS education.

I urge all medical students to learn how their desired specialty is reimbursed.

Orthopaedics has always been compensated well. It will continue to be compensated well. You are paid PER PROCEDURE. There is no law FORCING you to operate on everything that presents at your surgical center or clinic thus you will always be able to command a price per patient.

Even when bundled payments are fully rolled out (an effort by the ACA to curb fee for service), elective surgical specialists and fancy IM proceduralists will still be reimbursed well. They will still get that bundled amount for that entire healthcare event. They will just become smarter and more efficient regarding how to use that money in order to maintain the same margin. Additionally, these subspecialties are driven by device companies who are always upgrading, adding bells and whistles, and seeking to drive profits as well. Rest assured they will together find a way to pull money from the system.

Wasn't meant to be taken that way, more to point that this site always seems to be more on the doom side of actuality.

 

[exsanguination]

Wasn't meant to be taken that way, more to point that this site always seems to be more on the doom side of actuality.

Yea fair enough, I'll give you that

Everybody should do their own research, and formulate their own opinions. This even comes down to when your attending tells you "this is the way to take care of x, y, z." Learn from their experience, but always always always confirm (read the studies, papers, reviews, and textbooks) and formulate your own opinion.

 

[ZPakEffect]

If you can't see the difference between an ELECTIVE PROCEDURAL SPECIALTY and a specialty where you are MANDATED BY LAW (EMTALA) to see all patients REGARDLESS OF ABILITY TO PAY, then you are truly in need of SERIOUS education.

I urge all medical students to learn how their desired specialty is reimbursed.

Orthopaedics has always been compensated well. It will continue to be compensated well. You are paid PER PROCEDURE. There is no law FORCING you to operate on everything that presents at your surgical center or clinic thus you will always be able to command a price per patient.

Even when bundled payments are fully rolled out (an effort by the ACA to curb fee for service), elective surgical specialists and fancy IM proceduralists will still be reimbursed well. They will still get that bundled amount for that entire healthcare event. They will just become smarter and more efficient regarding how to use that money in order to maintain the same margin. Additionally, these subspecialties are driven by device companies who are always upgrading, adding bells and whistles, and seeking to drive profits as well. Rest assured they will together find a way to pull money from the system.

EMTALA is the hospital's problem, not the EP's problem, unless the EP is the one who owns the ED. Hospitals will still have to pay market rates to staff their EDs. If they don't staff their EDs, then they will have to shut them down and lose out on the money from ED admissions. You can see this with low-volume EDs where the EPs are paid guaranteed hourly rates regardless of how many patients they actually see. Around my area, hospital systems are still competing with each other to build as many EDs as possible in every suburb. If the CEOs of hospital systems are comfortable with investing tens of millions to build hospitals that won't pay themselves off for another decade, I'm pretty comfortable with where emergency medicine will be as a specialty in the future.

 

[Rekt]

EMTALA is the hospital's problem, not the EP's problem, unless the EP is the one who owns the ED. Hospitals will still have to pay market rates to staff their EDs. If they don't staff their EDs, then they will have to shut them down and lose out on the money from ED admissions. You can see this with low-volume EDs where the EPs are paid guaranteed hourly rates regardless of how many patients they actually see. Around my area, hospital systems are still competing with each other to build as many EDs as possible in every suburb. If the CEOs of hospital systems are comfortable with investing tens of millions to build hospitals that won't pay themselves off for another decade, I'm pretty comfortable with where emergency medicine will be as a specialty in the future.

Lol what? EPs are are either hired by the hospital or contracted through independent/private groups or CMGs. EPs have to follow EMTALA.

What is exsanguination is saying is 100% correct. There will always be a few groups/EPs that make decent-to-great money, but the overall trend in salary will be decreasing.

 

[ZPakEffect]

Lol what? EPs are are either hired by the hospital or contracted through independent/private groups or CMGs. EPs have to follow EMTALA.

What is exsanguination is saying is 100% correct. There will always be a few groups/EPs that make decent-to-great money, but the overall trend in salary will be decreasing.

You don't understand what I am saying. Yes, EPs are forced to see uninsured/underinsured patients by EMTALA, but they are shielded from the effects by the fact that they can just pick up and leave or demand an hourly guarantee if the billing gets too low. Many hospitals lose money on the ED, but still choose to operate it anyway to make more money from ED admissions. Hospitals are forced to pay EPs a competitive rate to staff their EDs, even if they are forced to take a loss.

The only factors that matter for determining EP compensation is the number of operating EDs and the number of EPs looking for a job. Judging by the number of EDs being built in my area, I feel pretty secure about the future of the specialty in this specific geographic location.

 

[exsanguination]

You don't understand what I am saying. Yes, EPs are forced to see uninsured/underinsured patients by EMTALA, but they are shielded from the effects by the fact that they can just pick up and leave or demand an hourly guarantee if the billing gets too low. Many hospitals lose money on the ED, but still choose to operate it anyway to make more money from ED admissions. Hospitals are forced to pay EPs a competitive rate to staff their EDs, even if they are forced to take a loss.

The only factors that matter for determining EP compensation is the number of operating EDs and the number of EPs looking for a job. Judging by the number of EDs being built in my area, I feel pretty secure about the future of the specialty in this specific geographic location.

You know, I'm rolling into a shift soon, and I don't feel like typing out all the reasons, but your understanding of compensation for ER docs is very very very poor.

It is far more nuanced than that.

And by the way, the fact that free standing EDs (which are not legal in all states, so I assume you're in ohio or texas) are able to spring up so quickly has more to do with the perverse incentives of the current system which are actively changing. This is A TEMPORARY CASH GRAB at best, and this windfall will not exist by the time you graduate from residency. Remember these are free standing EDs that are springing up, no FULL FLEDGED hospitals as you insinuate with your previous post. Hospital CEOs wouldn't be doubling down on FULL HOSPITALS, but it's easy and profitable RIGHT NOW to open up these EDs to funnel patients to their hospitals (because as you said, ED admissions are where the money comes from). In fact if you look deeper into the current state of health care economics, you'd realize that a good number of community hospitals are going to be or already are insolvent. Health care in the future will be economies of scale, and as hospital-based physicians, EPs are poised to do poorly.

Again, think as you will, research on your own, and formulate your own opinion.

 

[Postictal Raiden]

As for whether physicians will walk.. that depends. I think most doctors will continue to work. Look at the previous 2-3 decades. The doctors in the golden 80s and 90s, you know the FM docs that were pulling a mil/year back then, continued to work throughout the worsening reimbursement rates towards the late 90s that continue today.

I've yet to encounter a single evidence that doctors, on average, made significantly more money back in the "golden era". If you have any sources to back up this claim, please share.

 

[Postictal Raiden]

Double post

 

[ZPakEffect]

You know, I'm rolling into a shift soon, and I don't feel like typing out all the reasons, but your understanding of compensation for ER docs is very very very poor.

It is far more nuanced than that.

And by the way, the fact that free standing EDs (which are not legal in all states, so I assume you're in ohio or texas) are able to spring up so quickly has more to do with the perverse incentives of the current system which are actively changing. This is A TEMPORARY CASH GRAB at best, and this windfall will not exist by the time you graduate from residency. Remember these are free standing EDs that are springing up, no FULL FLEDGED hospitals as you insinuate with your previous post. Hospital CEOs wouldn't be doubling down on FULL HOSPITALS, but it's easy and profitable RIGHT NOW to open up these EDs to funnel patients to their hospitals (because as you said, ED admissions are where the money comes from). In fact if you look deeper into the current state of health care economics, you'd realize that a good number of community hospitals are going to be or already are insolvent. Health care in the future will be economies of scale, and as hospital-based physicians, EPs are poised to do poorly.

Again, think as you will, research on your own, and formulate your own opinion.

No, I am NOT referring to freestanding EDs. I am talking about full-fledged hospitals with EDs popping up like prairie dogs in every little suburb. It seems like every other exit on the freeway, there is a hospital with an ED and multiple billboards advertising the wait-time dotting the freeway. The freestanding EDs are beyond count.

 

[kenjixshadow]

EMTALA is the hospital's problem, not the EP's problem, unless the EP is the one who owns the ED.

The only factors that matter for determining EP compensation is the number of operating EDs and the number of EPs looking for a job.

How naive. Please put these comments in EM forum. Make sure you put them in bold and have the title in all cap. I would love to see EPs rip you apart again like what happened in the other thread made by you. For someone who claimed to have a JD and is working as a scribe, you have a poor understanding & did not do enough research of how ED levels are billed and the effects of EMTALA upon EM compensation. When large CMGs & ACEP are actively fighting against this bill, you can bet that it will greatly affect EM as a whole down the road.

they are shielded from the effects by the fact that they can just pick up and leave or demand an hourly guarantee if the billing gets too low. Many hospitals lose money on the ED, but still choose to operate it anyway to make more money from ED admissions. Hospitals are forced to pay EPs a competitive rate to staff their EDs, even if they are forced to take a loss.

Lol. No, they are not shielded from the effects. This is where you are wrong.

No, I am NOT referring to freestanding EDs. I am talking about full-fledged hospitals with EDs popping up like prairie dogs in every little suburb. It seems like every other exit on the freeway, there is a hospital with an ED and multiple billboards advertising the wait-time dotting the freeway. The freestanding EDs are beyond count.

You are from DFW. What you are seeing is not the norm in other area in US. Freestanding EDs can be lash down by legislation. Newly opening EDs, which are either manage by CMGs or democratic groups, are not going to pay you competitive rates when pts/insurance companies can choose to pay nothing.

 

[ZPakEffect]

How naive. Please put these comments in EM forum. Make sure you put them in bold and have the title in all cap. I would love to see EPs rip you apart again like what happened in the other thread made by you. For someone who claimed to have a JD and is working as a scribe, you have a poor understanding & did not do enough research of how ED levels are billed and the effects of EMTALA upon EM compensation. When large CMGs & ACEP are actively fighting against this bill, you can bet that it will greatly affect EM as a whole down the road.

Lol. No, they are not shielded from the effects. This is where you are wrong.

You are from DFW. What you are seeing is not the norm in other area in US. Freestanding EDs can be lash down by legislation. Newly opening EDs, which are either manage by CMGs or democratic groups, are not going to pay you competitive rates when pts/insurance companies can choose to pay nothing.

Yeah, I get it. On this board, if you are anything but a Chicken Little, you're going to get it coming to you. If emergency medicine is in trouble, if EDs are not going to be profitable, if freestanding EDs can be wiped clean so easily, then all these CEOs and investors are *****s for doing all this overbuilding, and a bunch of hospital systems and freestanding ED chains are going to go bankrupt. It's possible, but I think these guys might know a bit more about the current and future climate than a bunch of negative nancies on the internet.

 

[link2swim06]

Yea, I think within 3-4 years the EM heyday will be over and we can expect salaries closer to 175-200k/year. There's no way the system can continue as it is, and looking at current legislation (balanced billing any one?), the downward pressure on EMTALA bound physicians' salaries will continue until it becomes a matter of large-scale life/death or access.

Doubtful.

 

[Psai]

Yeah, I get it. On this board, if you are anything but a Chicken Little, you're going to get it coming to you. If emergency medicine is in trouble, if EDs are not going to be profitable, if freestanding EDs can be wiped clean so easily, then all these CEOs and investors are *****s for doing all this overbuilding, and a bunch of hospital systems and freestanding ED chains are going to go bankrupt. It's possible, but I think these guys might know a bit more about the current and future climate than a bunch of negative nancies on the internet.

If you think you know all the answers, why are you here? To show off what you think you know?

 

[Psai]

.

 

[Slack3r]

The same thing will happen to hospitalists too. Any large multi-state contract management group (CMG) or hospital-based physician will end up facing these downward salary pressures. Urgent cares, outpatient clinics... they will all face the same result.

Go ahead and ask any hospitalist at your institution about what's happening to their reimbursement.

Hospitalists and EM docs are similar in this regard and will face many of the same challenges.

As for whether physicians will walk.. that depends. I think most doctors will continue to work. Look at the previous 2-3 decades. The doctors in the golden 80s and 90s, you know the FM docs that were pulling a mil/year back then, continued to work throughout the worsening reimbursement rates towards the late 90s that continue today.

How many docs do you know that reluctantly trudge onwards despite continuously complaining about decreasing reimbursement? I know quite a few. At the end of the day you need money to pay for your kids' college, your mortgage, your divorce alimony/child support, your loans, your inflating lifestyle etc etc etc.

I think fellowship will come more popular sure, but there are very few EM fellowships that INCREASE ones salary. The only ones I can think of really are POTENTIALLY pain medicine and critical care. Otherwise every other EM fellowship potentially results in a decrease (there are no tox jobs out there, US doesn't pay more just allows you to work less, EMS same thing as US, admin same thing as US. Tactical medicine, wilderness medicine, simulation, and other fringe non-accredited fellowships also don't pay. I forget whether these are accredited or not actually, but the point remains).

The key to financial freedom in medicine is simple. There are TWO ROUTES:

1. Non-surgical subspecialty and non-cash-based specialty: be frugal, live like a resident, invest wisely and you can live with your 200k/year salary

2. Pursue a surgical subspecialty or cash based specialty. Ball out as desired. FYI this category includes things like interventional cards and other specialized procedure based specialties.

Why you think the surgical sub specialties are immune to declining reimbursements is beyond me. No field is safe.

 

[Cinematographer]

If you think you know all the answers, why are you here? To show off what you think you know?

Isn't that 99% of SDN, though? I don't see the issue with ZPackeffect providing a different perspective than that shared in exsanguination's Trump-esque, "EM is doomed" know-it-all posts. It's what keeps things somewhat balanced on this forum.

 

[Psai]

Isn't that 99% of SDN, though? I don't see the issue with ZPackeffect providing a different perspective than that shared in exsanguination's Trump-esque, "EM is doomed" know-it-all posts. It's what keeps things somewhat balanced on this forum.

Because he is a premed who argues with em attendings in the emergency section here about what working in the ed is actually like according to his perspective as a scribe. It's not really balancing when there is no legitimacy

 

[Cinematographer]

Because he is a premed who argues with em attendings in the emergency section here about what working in the ed is actually like according to his perspective as a scribe. It's not really balancing when there is no legitimacy

I see. Thought he was at least a resident.

 

[asdf123g]

Theres a fairly lengthy thread in the EM forum regarding the new legislation in regards to reimbursements which the EM people seemed to be very concerned about. If anything the amount of commotion its caused there, adds legimitmacy to exsanguination. Just saying...

 

[mCATintheHAT123]

RIP EM:
http://newsroom.acep.org/2015-12-01...airly-for-Emergency-Care-Under-New-Regulation

 

[W19]

RIP EM:
http://newsroom.acep.org/2015-12-01...airly-for-Emergency-Care-Under-New-Regulation

I guess it won't take that long for the bubble to burst...

 

[LostinLift]

RIP EM:
http://newsroom.acep.org/2015-12-01...airly-for-Emergency-Care-Under-New-Regulation

Old news is old, this is the issue that sparked the debate...

300k+/-100k is not overpaid or a "heydey" for a physician, other physicians are just underpaid.