Moving south?

[Doctor J]

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So I've finally convinced my wife that the northeast (with it's dismal EM pay, enormous property taxes, high personal income tax rates, litigious patient mix, and snow snow snow) is not the best place for us to set roots. Each time I see a regional salary report I die a little inside. It's been home for our entire lives, but we're ready to strike for greener pastures.

I'm not interested in recruiters as in essence they are skimming the cream from my labors. Otherwise I'd just respond to one of the dozen emails/phone calls/postcards I get each day. Does anyone have any geographic areas they can suggest as likely spots to raise a family (and hopefully land a nice position in the bargain)? I know the southeast is hot right now, I'm looking for more specific advice. I know next to nothing about this region of the country but I'm learning more every day.

 

[Perrin]

That's a hell of a question. Like everything, it depends on what you are looking for.

Is a nice position in academics, private hospital, rural, or urban? I've spent about 20 years living, traveling, and training in a few places in the SE, so I'll give it a shot.

TN
Like most of the south, metro areas are scattered far from each other. Metro areas have the majority of the large ER's like Memphis, Nashville, Chatanooga, and Knoxville. These places have your large academic sites. The surrounding burbs and counties are the lower level trauma centers. I didn't look for a job in TN, so I don't know what the pay typically is.

MS
Very rural state with the big hospitals in Tupelo, Jackson, Meridian, and Hattiesburg. Jackson has the UM medical school for academics. North and central MS are mostly farms and timber scattered with small towns. The delta, poorest area of the country is the most medically under served, but the birthplace of the blues. The MS gulf coast is kind of a bridge between NOLA and the Florida panhandle. There are a few hospitals scattered through Gulfport, Biloxi, and Ocean Springs. I think most of these ED's are managed by CMG's like Team Health and the Schumacher Group. The pay is decent with a low cost of living. The schools vary from good in Ocean Springs to seemingly inner city in Gulfport. The lifestyle is pretty laid back b/c it's on the Gulf. Katrina delt a big blow to the area, but its recovering. Housing prices are low, casino money helps fund local projects, and you are only 90 min from NOLA or the FL beaches. If you want a decent sized city or academics, Jackson would work. If you want a laid back lifestyle, the gulf coast is it.

LA
Louisiana is kind of like 2 states. The north half has Monroe and Shreveport while the south half has New Orleans and Baton Rouge. There are 3 EM residencies in LA and a lot of their grads are from LA or plan to stay there. Thus, the market is a little saturated. The pay is a little bit lower in these areas. There are a lot of hospitals in BR and NO and most have CMG'S. However, the lifestyle makes up for it. C'mon it's Cajun country. They have parades and parties for any holiday. The food is great, if you like seafood. The schools are terrible and most people send their kids to private schools if they can afford it.

AL
It's a little bit more populated then MS. Birmingham and Mobile have med schools. Huntsville and Montgomery round out the list of "metro" areas. There are plenty of CMG'S and a few doc groups that staff EDs. Mobile is on the coast if your looking for the Gulf lifestyle. UAB Birmingham has academics and is only 45 minutes from Tuscaloosa if you feel the urge to yell Roll Tide. Huntsville has a large research and military industry economy. Most places in AL are a few hours drive from a major city, be it Atlanta, New Orleans, Nashville, or the Beach. There is only 1 EM residency in AL at UAB, so the state is not near as saturated as LA. I think there is a DO school opening up in Dothan. Most of the EDs in the rural areas are small and transfer to the larger cities.

I'll defer to other folks about the other areas of the SE.

 

[Hercules]

Good summary. I'll plug Mobile and also tell you that I am part of a SDG of all EM residency trained docs that is hiring for a spot in 2015. PM me if interested in more details.

 

[Old_Mil]

Just leave the voting patterns that made the northeast what it is behind if you come to dixie.

Sent from my Z10 using Tapatalk

 

[EM Junkie]

Our small democratic group in Houston is expanding to cover a new hospital and 2 freestandings. We're looking to hire if the right person comes along.

PM me your CV/contact info if interested!

 

[Doctor J]

Thanks all. The comment above about being specific about what I'm looking for is spot-on. I should have put this info in the first post.

Medium sized city or small, non academic, small democratic group (ideal but not required), collegial group, and low cost of living is what I'm looking for. Ideally southeast. Coastal is not required, I'm willing to be inland - real estate tends to be cheaper there. And I'm EM residency trained. If you have any info please feel free to PM me.

 

[EMDoc0411]

I run a free standing in Austin. We are looking to expand and build more. PM if interested.

 

[VA Hopeful Dr]

Look at SC. We're cheap, coastal, good schools if you're in the right places, and still a pretty doctor-friendly place.

 

[GeneralVeers]

Texas is generally your best bet.

-No state income tax (can save you about $30,000 per year!)
-Excellent malpractice environment
-Lots of "medium-sized cities"
-Cheap real estate
-No snow
-Two large international airport hubs makes getting anywhere in the country/world fairly easy.

 

[Fluffy Pomeranian]

PMed you

 

[dchristismi]

Texas may be your best bet, but I'm in inland Florida, small-med sized town, academic perks as we're affiliated with a residency but pretty much a community practice, and we may also have an opening. We also have Sovereign Immunity, which makes practicing in Florida tolerable

 

[Hercules]

Can we make this post a sticky? It may settle nerves the next time it comes up that the sky is falling or that there aren't good jobs to be found in emergency medicine.

 

[GeneralVeers]

Texas is one of the few bright spots. I've actually seen reimbursement go up a lot there in the last 5 years! In some case it has gone up 60-75%!! A lot of rural hospitals and rapidly expanding groups/systems have realized that to fill their needs with BCEM docs they are going to have to pay a premium to get people to travel there as locums, or move. I also have some friends who work in Florida, and they are doing very well too, with pay that has gone up a similar amount.

 

[EM_Rebuilder]

Texas.

Pay has been driven up by the 100+ FSEDs built in the last 3-7 years. If you figure 5 docs per, that's 500 more ER spots alone. That is NOT counting the increased demands every ER has seen with the ACA and such.. Also, many new hospitals have been built across our great state.

Supply and demand.

Concerns? FSED Bubble. Say the plug gets pulled and FSEDs get a huge decrease in the facility fee. The EM market will be dismal in Texas... although many of those attracted here by high pay would likely leave.

No state income tax, best malpractice coverage in the county, friendly people, pro small business... What is there not to like about Texas? 100 degree days, but we have A/C for that...

 

[Arcan57]

FSED bubble is real and will likely pop in <5 yrs, although I'm hearing more and more that it's going to be the insurance company lawsuits that kill them off rather than legislative action. That will make a huge difference to the owners of the FSEDs, but I don't think that docs that are attracted by the high pay are the ones working FSEDs. What FSEDs closing would do is dump a bunch of late career EPs who don't quite have enough to retire back into the market and probably strand some non-EM trained docs into UC work.

While the FSEDs are employing more docs than seeing the equivalent number of patients in traditional EDs. the main drivers in the market are still the expanding population and robust economy. Barring our sudden discovery of an abundant energy source that's cheaper to extract and use then oil, TX should remain in good shape.

 

[GeneralVeers]

FSED bubble is real and will likely pop in <5 yrs, although I'm hearing more and more that it's going to be the insurance company lawsuits that kill them off rather than legislative action. That will make a huge difference to the owners of the FSEDs, but I don't think that docs that are attracted by the high pay are the ones working FSEDs. What FSEDs closing would do is dump a bunch of late career EPs who don't quite have enough to retire back into the market and probably strand some non-EM trained docs into UC work.

While the FSEDs are employing more docs than seeing the equivalent number of patients in traditional EDs. the main drivers in the market are still the expanding population and robust economy. Barring our sudden discovery of an abundant energy source that's cheaper to extract and use then oil, TX should remain in good shape.

I agree with what you said. Most of the FSEDS do not pay highly, and are around $130-$150/hr compensation. The highly paid jobs tend to be in smaller city, full-service hospitals that want BCEM doctors, but due to location have difficulty attracting people. Hence the higher salaries. In my opinion those jobs are reasonably safe as demand will remain constant regardless of the FSED bubble.

 

[Birdstrike]

FSED bubble is real and will likely pop in <5 yrs, although I'm hearing more and more that it's going to be the insurance company lawsuits that kill them off rather than legislative action. That will make a huge difference to the owners of the FSEDs, but I don't think that docs that are attracted by the high pay are the ones working FSEDs. What FSEDs closing would do is dump a bunch of late career EPs who don't quite have enough to retire back into the market and probably strand some non-EM trained docs into UC work.

While the FSEDs are employing more docs than seeing the equivalent number of patients in traditional EDs. the main drivers in the market are still the expanding population and robust economy. Barring our sudden discovery of an abundant energy source that's cheaper to extract and use then oil, TX should remain in good shape.

I don't have a dog in this fight, but I'm curious why you think there's an FSED "bubble" and what it is that's going to burst that bubble. Pray tell.

 

[Arcan57]

I don't have a dog in this fight, but I'm curious why you think there's an FSED "bubble" and what it is that's going to burst that bubble. Pray tell.

I think there is an FSED "bubble" because the current business model (at least in TX) is built around being able to charge facility fees to predominantly ESI IV and V patients while keeping a very low overhead with very high reimbursement rate from private insurance. I'm not saying this is the only way to set up a FSED, but it's the model that's proliferating here and it's a vulnerable set-up.

My reasons on why I think the bubble is going to burst (from weakest to strongest):
1) Physicians can't have nice things - the general trend in medicine has been to deny physicians (and non-hospital based groups in general) opportunities for profit. Shackles on physician owned hospitals, nerfing payment for outpatient imaging centers, reimbursing at a higher rate for in-hospital procedures - this is a temporal trend I don't see going away. Especially with the current push to consolidate healthcare into neatly managed ACOs.

2) Lobbying pressure from hospitals - at some point hospitals are going to realize that the handful of admits they get a month from the FSED are coming at the cost of significant lost revenue from the excellent payor mix the FSEDs are skimming off. With only 1 or 2 FSED seeing 8-12 patients a day it's not a noticeable effect, but when there are a half dozen plus FSEDs in each hospital's catchment area they're going to start to notice. And hospitals have a proven track record of being able to ruthlessly defend their interests at the state and federal level. And while the majority of FSEDs aren't beholden to federal laws, many states have EMTALA like rules for who can call themselves an ED and what services they must provide. From multiple conversations with EMS chiefs, some of the FSEDs are deep into the gray areas of state law in terms of how they're handling patients that are unresourced.

3) Insurance companies - multiple companies are now involved in high dollar litigation regarding charges generated from FSED visits. If insurance companies can weasel out of paying facility fees, the entire model collapses. Talking to owners of FSEDs, the time to recoup investment is short enough that they're still putting up FSEDs now but the majority don't expect the business model to be sustainable and they look at it as an investment not a career.

 

[Birdstrike]

I think there is an FSED "bubble" because the current business model (at least in TX) is built around being able to charge facility fees to predominantly ESI IV and V patients while keeping a very low overhead with very high reimbursement rate from private insurance. I'm not saying this is the only way to set up a FSED, but it's the model that's proliferating here and it's a vulnerable set-up.

My reasons on why I think the bubble is going to burst (from weakest to strongest):
1) Physicians can't have nice things - the general trend in medicine has been to deny physicians (and non-hospital based groups in general) opportunities for profit. Shackles on physician owned hospitals, nerfing payment for outpatient imaging centers, reimbursing at a higher rate for in-hospital procedures - this is a temporal trend I don't see going away. Especially with the current push to consolidate healthcare into neatly managed ACOs.

2) Lobbying pressure from hospitals - at some point hospitals are going to realize that the handful of admits they get a month from the FSED are coming at the cost of significant lost revenue from the excellent payor mix the FSEDs are skimming off. With only 1 or 2 FSED seeing 8-12 patients a day it's not a noticeable effect, but when there are a half dozen plus FSEDs in each hospital's catchment area they're going to start to notice. And hospitals have a proven track record of being able to ruthlessly defend their interests at the state and federal level. And while the majority of FSEDs aren't beholden to federal laws, many states have EMTALA like rules for who can call themselves an ED and what services they must provide. From multiple conversations with EMS chiefs, some of the FSEDs are deep into the gray areas of state law in terms of how they're handling patients that are unresourced.

3) Insurance companies - multiple companies are now involved in high dollar litigation regarding charges generated from FSED visits. If insurance companies can weasel out of paying facility fees, the entire model collapses. Talking to owners of FSEDs, the time to recoup investment is short enough that they're still putting up FSEDs now but the majority don't expect the business model to be sustainable and they look at it as an investment not a career.

You may be right. Here's why:

The current system is set up to create the impression costs will be driven down (even though they won't), by reducing what physicians are payed and by reducing the amount of care patients are given (buzzword = "unnecessary" care) while maximizing profits for hospital administrators and shareholders, politicians and insurance company administrators and shareholders.

Despite all the BS talk of "patient satisfaction," "patient centered care," and "medical homes," the whole concept of reducing costs comes down to reducing care delivered to patients (rationing) and reducing what physicians are payed to deliver it. Absolutely none of the power players are factoring in any reduction in their own salaries or profits for managing the health-care/policies/insurance, ie, those of the power players in government, policy, insurance companies and hospitals. That's absolutely off the table.

Therefore, outrageously inflated facility fees which are and have payed to hospitals (hundreds of percents higher than identical procedures done in private physicians offices) are payed without hesitation and without complaint from the hypocritical power players claiming a desire to reduce costs and wasteful spending. It wouldn't surprise me if these higher facility fees to physician-owned FSEDs get crushed, since physicians are already on the gallows pole for being "rich and greedy" while truly rich and greedy hospital CEOs and politicians get a pass. This could easily happen, while even more bloated and wasteful hospital facility go on untouched.

The whole system is rigged, not to first provide care, but to first deliver profits to hospital and insurance co. administrators and shareholders, and politicians and policy makers. If patients get "care," and physicians earn what they deserve in the process, that's secondary.

 

[Arcan57]

You may be right. Here's why:

The current system is set up to create the impression costs will be driven down (even though they won't), by reducing what physicians are payed and by reducing the amount of care patients are given (buzzword = "unnecessary" care) while maximizing profits for hospital administrators and shareholders, politicians and insurance company administrators and shareholders.

Despite all the BS talk of "patient satisfaction," "patient centered care," and "medical homes," the whole concept of reducing costs comes down to reducing care delivered to patients (rationing) and reducing what physicians are payed to deliver it. Absolutely none of the power players are factoring in any reduction in their own salaries or profits for managing the health-care/policies/insurance, ie, those of the power players in government, policy, insurance companies and hospitals. That's absolutely off the table.

Therefore, outrageously inflated facility fees which are and have payed to hospitals (hundreds of percents higher than identical procedures done in private physicians offices) are payed without hesitation and without complaint from the hypocritical power players claiming a desire to reduce costs and wasteful spending. It wouldn't surprise me if these higher facility fees to physician-owned FSEDs get crushed, since physicians are already on the gallows pole for being "rich and greedy" while truly rich and greedy hospital CEOs and politicians get a pass. This could easily happen, while even more bloated and wasteful hospital facility go on untouched.

The whole system is rigged, not to first provide care, but to first deliver profits to hospital and insurance co. administrators and shareholders, and politicians and policy makers. If patients get "care," and physicians earn what they deserve in the process, that's secondary.

Agreed.

 

[deleted126335]

So I've finally convinced my wife that the northeast (with it's dismal EM pay, enormous property taxes, high personal income tax rates, litigious patient mix, and snow snow snow) is not the best place for us to set roots. Each time I see a regional salary report I die a little inside. It's been home for our entire lives, but we're ready to strike for greener pastures.

I'm not interested in recruiters as in essence they are skimming the cream from my labors. Otherwise I'd just respond to one of the dozen emails/phone calls/postcards I get each day. Does anyone have any geographic areas they can suggest as likely spots to raise a family (and hopefully land a nice position in the bargain)? I know the southeast is hot right now, I'm looking for more specific advice. I know next to nothing about this region of the country but I'm learning more every day.

If you are relocating to a region of the country where your wife has no family connections, I would strongly suggest that you give serious considerations to her views on the community- work opportunities, culture, etc. Moving a city girl to the country and saying "go make friends and have fun" is not a recipe for success. Being "an hour" from a big city is a world of difference than being in the city or immediate suburbs. Saw more than one marriage ruined by not giving enough consideration to this issue.