NES healthcare

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I'm really ignorant about ED physician reimbursement. Why is it that hospitals don't hire and pay ED MDs directly? This seems like a bizarre permanent locums situation that hospitals put themselves in. It can't possibly be cost effective.
 
I'm really ignorant about ED physician reimbursement. Why is it that hospitals don't hire and pay ED MDs directly? This seems like a bizarre permanent locums situation that hospitals put themselves in. It can't possibly be cost effective.
They need a pool of docs. ED docs are often transient beings. What would you do if you have 6 docs and 1 gets sick. Where do you find coverage? Some states like California and Texas prohibit it altogether. What happens when 1 is pregnant and the other quits. In a solo coverage site you are screwed. In the hospital you can just not do surgeries, or not admit patients but in the ED it’s gotta stay open.
 
They need a pool of docs. ED docs are often transient beings. What would you do if you have 6 docs and 1 gets sick. Where do you find coverage? Some states like California and Texas prohibit it altogether. What happens when 1 is pregnant and the other quits. In a solo coverage site you are screwed. In the hospital you can just not do surgeries, or not admit patients but in the ED it’s gotta stay open.
EM docs are like truck drivers. They all do the same thing, and some truckers even have the same model truck. But, they're all individual. The EM docs have just them, their skillset, and their own baggage. No staff, no buildings, nothing substantial. All individuals. Neither can, per se, unionize.

And, we're all too proud and too stuck on ourselves that we're all the most BAMFED, that there can't be any progress.
 
I'm really ignorant about ED physician reimbursement. Why is it that hospitals don't hire and pay ED MDs directly? This seems like a bizarre permanent locums situation that hospitals put themselves in. It can't possibly be cost effective.
Some hospitals do. Especially some large county hospitals or academic places. A lot of community hospitals and even some big tertiary care places can't be bothered. You have to hire a bunch of docs, replace them when they quit, bill and collect for their services, have a back office to manage all that, basically everything that comes with running a group practice. In the old days a community hospital would just contract with a local group of EM physicians or in the really old days some random collection of docs who were willing to staff the ED. Now days many of those small local groups have been swallowed up by small(like NES) or large(like USACS) multistate CMG's. The hospital just makes an agreement with the CMG and the CMG does everything else. As long as the CMG doesn't implode or staff the place into the ground the hospital can quit worrying about who is staffing their ED. Many hospitals have similar arrangements for radiology, anesthesia, and other hospital based specialties they need. Same with hospitalist except they often lose money so the CMG's throw a free hospitalist contract in when they are given the money making contracts to staff the ED, anesthesia, or rads, etc...

Of course if the CMG does implode or cut staffing to the point the community hates the place then the hospital gets left with their pants down.
 
Some hospitals do. Especially some large county hospitals or academic places. A lot of community hospitals and even some big tertiary care places can't be bothered. You have to hire a bunch of docs, replace them when they quit, bill and collect for their services, have a back office to manage all that, basically everything that comes with running a group practice. In the old days a community hospital would just contract with a local group of EM physicians or in the really old days some random collection of docs who were willing to staff the ED. Now days many of those small local groups have been swallowed up by small(like NES) or large(like USACS) multistate CMG's. The hospital just makes an agreement with the CMG and the CMG does everything else. As long as the CMG doesn't implode or staff the place into the ground the hospital can quit worrying about who is staffing their ED. Many hospitals have similar arrangements for radiology, anesthesia, and other hospital based specialties they need. Same with hospitalist except they often lose money so the CMG's throw a free hospitalist contract in when they are given the money making contracts to staff the ED, anesthesia, or rads, etc...

Of course if the CMG does implode or cut staffing to the point the community hates the place then the hospital gets left with their pants down.
Carolina Emergency Medicine, in Greenville SC, was so big, they spun off Spartanburg EM. The boss said that they were the largest group in the Southeast that wasn't a CMG.They staffed 4 hospitals in Greenville County. CEMPA, when I worked for them, I don't even know who did the billing, because there were partners, partner track associates, and part timers. But no office. Checks came from CEMPA.

The Greenville Health System was looking to expand. They bought up private offices, an Ortho group, and a cardiology group, for untold millions. But, what did they do for CEMPA, with about 60 doctors? I estimated $100mil, maybe a buck and a quarter. But ...

GHS waited until the contract was up. This was fortuitous for them, because it wasn't that long until it was coming due. And, they didn't re-up. Docs had the choice to stay or go. There was only one other hospital in Greenville. A few docs moved over there. But, most stayed - and became employees. GHS got the group for free. Moreover, it became an EM residency - which was a huge reason why people originally joined the group, that they were NOT teaching. The off service residents fumbled around, and we didn't really bother with them. But, then, it went from the frying pan into the fire.

Reminds me of the song "Jesus' Brother Bob", by the Arrogant Worms, from Canada.

I always pay the fare
To cross the Galilee
But not my brother Jesus "no, not him"
He just walks across for free!
 
I'm really ignorant about ED physician reimbursement. Why is it that hospitals don't hire and pay ED MDs directly? This seems like a bizarre permanent locums situation that hospitals put themselves in. It can't possibly be cost effective.
Honestly because they are not that good at it, oftentimes...
Our private group does a heck of a better job.
 
Carolina Emergency Medicine, in Greenville SC, was so big, they spun off Spartanburg EM. The boss said that they were the largest group in the Southeast that wasn't a CMG.They staffed 4 hospitals in Greenville County. CEMPA, when I worked for them, I don't even know who did the billing, because there were partners, partner track associates, and part timers. But no office. Checks came from CEMPA.

The Greenville Health System was looking to expand. They bought up private offices, an Ortho group, and a cardiology group, for untold millions. But, what did they do for CEMPA, with about 60 doctors? I estimated $100mil, maybe a buck and a quarter. But ...

GHS waited until the contract was up. This was fortuitous for them, because it wasn't that long until it was coming due. And, they didn't re-up. Docs had the choice to stay or go. There was only one other hospital in Greenville. A few docs moved over there. But, most stayed - and became employees. GHS got the group for free. Moreover, it became an EM residency - which was a huge reason why people originally joined the group, that they were NOT teaching. The off service residents fumbled around, and we didn't really bother with them. But, then, it went from the frying pan into the fire.

Reminds me of the song "Jesus' Brother Bob", by the Arrogant Worms, from Canada.

I always pay the fare
To cross the Galilee
But not my brother Jesus "no, not him"
He just walks across for free!
This works in desireable locations. Sometimes in undesireable ones as well. IN general herding EM docs is hard. Our culture is broken in my opinion. It is the result of the CMG abuse of docs. Wouldn’t it be better to work 10-20 mins from home? Work in your community rather than do locums. Locums should exist to fill emergency holes and not a constant issue due to dysfunction. The CMGs were wise to create their own internal locums pool. All the big groups Vituity, USACS TH have this setup.

Allows them to pass along costs to the hospitals but keep the profits internally. Frankly it is genius as a biz strategy for them. Vituity was paying $300/hr for their “travel” team this seems insanely low. I am guessing they have a fair number of these people.
 
This works in desireable locations. Sometimes in undesireable ones as well. IN general herding EM docs is hard. Our culture is broken in my opinion. It is the result of the CMG abuse of docs. Wouldn’t it be better to work 10-20 mins from home? Work in your community rather than do locums. Locums should exist to fill emergency holes and not a constant issue due to dysfunction. The CMGs were wise to create their own internal locums pool. All the big groups Vituity, USACS TH have this setup.

Allows them to pass along costs to the hospitals but keep the profits internally. Frankly it is genius as a biz strategy for them. Vituity was paying $300/hr for their “travel” team this seems insanely low. I am guessing they have a fair number of these people.
I think the travel rate for TH was like $270/hour 7-8 years ago. Still seemed low at the time.
 
I'm really ignorant about ED physician reimbursement. Why is it that hospitals don't hire and pay ED MDs directly? This seems like a bizarre permanent locums situation that hospitals put themselves in. It can't possibly be cost effective.
I think it dates back to concerns of violating Starke laws (i.e., physician employed by the hospital admits patients and therefore causes kickbacks to the hospital). I've heard this discussed by C suite people before, but I don't think it's ever been tested.
 
The docs shouldn’t have been showing up once they knew they weren’t getting paid.
Last year when I and a few docs refused to work after NES refused pay after a month of delayed wages this is what one of the older docs sent out via mass email:


"Your selfishness is going to hurt someone— and that person is Dr. *** (ED Director).

Plain and simple.

I sit back and just shake my head at how money has caused several of you to take a stance that somehow you think has any impact on NES. Well, it doesn’t. But it has incredible impact on your colleagues. It leaves your colleague who has been working for 12 hours straight- abandoned by your desire to not show up.

If this is your solution— you have certainly demonstrated how linearly you see your role in our emergency room. You have demonstrated how little you think about your value and the impact it has on your fellow physicians. You demonstrate clearly how self-centered you can be, that you leave it to Dr. Kong to try to find a solution to a real-world problem you created.

Where is your morality when you leave an emergency department for the other physicians and midlevels to try to cover the hole you left, while you sit at home taking your stance? Where are your ethics? Apparently it stops at the edges of the mighty dollar bill.

People, sometimes you are going to be caught in a dilemma, where your character is tested just as much as your will—this is one of those moments.

I know this is going to sound foreign to a lot of you. My promise to cover a shift is a promise. It’s about respect for others, its about service to a community of people that need the service, its about knowing these patient’s stories and their fears and their concerns and being the one person they hope to rely on. When I enter the ER to assume the responsibility as the physician of record, I represent myself, I represent my alma mater, I represent my training, I represent my parents and how they raised me, I represent my children and how I raised them.

—It’s not about you.

Now, go share your actions with the person in the mirror and your loved ones, how to act when you don’t get your way.

It’s chicken-****, and it’s unprofessional, and demonstrates your lack of character.

Dr. *** (ED Director), I thank you for every minute of every hour of every day that you have endured as the director of this emergency room, under such incredible pressures.

…and my name is Joe ***, MD."


This is the problem of division we face in Emergency medicine.
 
Loyalty to the ED isn't the same as loyalty to your country or your family. I get the angle the guy is going for but I don't consider that a healthy attitude. At some point, people need to put food on the table.

Whoever wrote that has clearly drilled into his head that he's just a cog with a singular purpose of working the ed and I can't imagine that's a satisfying way to live.

I won't knock him personally for it, I totally get for some people their job is their purpose, but I wouldn't blanket apply that to all other docs with that tone.

Some people, like me, are just happy to survive this world and have fun.
 
Last year when I and a few docs refused to work after NES refused pay after a month of delayed wages this is what one of the older docs sent out via mass email:


"Your selfishness is going to hurt someone— and that person is Dr. *** (ED Director).

Plain and simple.

I sit back and just shake my head at how money has caused several of you to take a stance that somehow you think has any impact on NES. Well, it doesn’t. But it has incredible impact on your colleagues. It leaves your colleague who has been working for 12 hours straight- abandoned by your desire to not show up.

If this is your solution— you have certainly demonstrated how linearly you see your role in our emergency room. You have demonstrated how little you think about your value and the impact it has on your fellow physicians. You demonstrate clearly how self-centered you can be, that you leave it to Dr. Kong to try to find a solution to a real-world problem you created.

Where is your morality when you leave an emergency department for the other physicians and midlevels to try to cover the hole you left, while you sit at home taking your stance? Where are your ethics? Apparently it stops at the edges of the mighty dollar bill.

People, sometimes you are going to be caught in a dilemma, where your character is tested just as much as your will—this is one of those moments.

I know this is going to sound foreign to a lot of you. My promise to cover a shift is a promise. It’s about respect for others, its about service to a community of people that need the service, its about knowing these patient’s stories and their fears and their concerns and being the one person they hope to rely on. When I enter the ER to assume the responsibility as the physician of record, I represent myself, I represent my alma mater, I represent my training, I represent my parents and how they raised me, I represent my children and how I raised them.

—It’s not about you.

Now, go share your actions with the person in the mirror and your loved ones, how to act when you don’t get your way.

It’s chicken-****, and it’s unprofessional, and demonstrates your lack of character.

Dr. *** (ED Director), I thank you for every minute of every hour of every day that you have endured as the director of this emergency room, under such incredible pressures.

…and my name is Joe ***, MD."


This is the problem of division we face in Emergency medicine.
That’s a lot of words but if you’re employed and your employer isn’t paying then you’d be an idiot to keep showing up. This is how corporate medicine takes advantage of weak physicians.
 
That’s a lot of words but if you’re employed and your employer isn’t paying then you’d be an idiot to keep showing up. This is how corporate medicine takes advantage of weak physicians.
Agreed. This attitude is dumb. I love my group. Genuinely. My SDG has provided both professional meaning for me as well as tremendous financial success. That being said if the checks stop coming so do I. Full stop. It’s not about the patients, it’s not about the hospital. It’s about me and my family. If I want to do medical volunteer work I can (and do). But this is a job and the other part of the job is the part where they have someone enter numbers in a computer and those numbers show up in my bank account. It’s work, it’s a job the equation is i provide a service and they provide a paycheck (whether i need it or not).
 
Agreed. This attitude is dumb. I love my group. Genuinely. My SDG has provided both professional meaning for me as well as tremendous financial success. That being said if the checks stop coming so do I. Full stop. It’s not about the patients, it’s not about the hospital. It’s about me and my family. If I want to do medical volunteer work I can (and do). But this is a job and the other part of the job is the part where they have someone enter numbers in a computer and those numbers show up in my bank account. It’s work, it’s a job the equation is i provide a service and they provide a paycheck (whether i need it or not).
Not to mention lack of malpractice coverage. My benevolence doesn’t extend as far to work without it.
 
Agreed. This attitude is dumb. I love my group. Genuinely. My SDG has provided both professional meaning for me as well as tremendous financial success. That being said if the checks stop coming so do I. Full stop. It’s not about the patients, it’s not about the hospital. It’s about me and my family. If I want to do medical volunteer work I can (and do). But this is a job and the other part of the job is the part where they have someone enter numbers in a computer and those numbers show up in my bank account. It’s work, it’s a job the equation is i provide a service and they provide a paycheck (whether i need it or not).

Here's a thought experiment for you to answer.

Suppose your group said there was a "problem" and your check was delayed by one month.

What do you do?

Stop working? If you credential elsewhere you're still a month+ out from getting another check.

I mean I don't support it either but I've not been in this situation and I could probably be convinced to string along in hopes all goes well eventually rather than credential elsewhere.
 
Here's a thought experiment for you to answer.

Suppose your group said there was a "problem" and your check was delayed by one month.

What do you do?

Stop working? If you credential elsewhere you're still a month+ out from getting another check.

I mean I don't support it either but I've not been in this situation and I could probably be convinced to string along in hopes all goes well eventually rather than credential elsewhere.
There's a difference between being employed vs. being self-employed in an SDG. If your employer is to the point that it can't meet payroll (meaning they've already exhausted all their lines of credit, etc.) then that company is done for and you should find another job immediately and quit working for free. This extends to basically any industry.
 
Last year when I and a few docs refused to work after NES refused pay after a month of delayed wages this is what one of the older docs sent out via mass email:


"Your selfishness is going to hurt someone— and that person is Dr. *** (ED Director).

Plain and simple.

I sit back and just shake my head at how money has caused several of you to take a stance that somehow you think has any impact on NES. Well, it doesn’t. But it has incredible impact on your colleagues. It leaves your colleague who has been working for 12 hours straight- abandoned by your desire to not show up.

If this is your solution— you have certainly demonstrated how linearly you see your role in our emergency room. You have demonstrated how little you think about your value and the impact it has on your fellow physicians. You demonstrate clearly how self-centered you can be, that you leave it to Dr. Kong to try to find a solution to a real-world problem you created.

Where is your morality when you leave an emergency department for the other physicians and midlevels to try to cover the hole you left, while you sit at home taking your stance? Where are your ethics? Apparently it stops at the edges of the mighty dollar bill.

People, sometimes you are going to be caught in a dilemma, where your character is tested just as much as your will—this is one of those moments.

I know this is going to sound foreign to a lot of you. My promise to cover a shift is a promise. It’s about respect for others, its about service to a community of people that need the service, its about knowing these patient’s stories and their fears and their concerns and being the one person they hope to rely on. When I enter the ER to assume the responsibility as the physician of record, I represent myself, I represent my alma mater, I represent my training, I represent my parents and how they raised me, I represent my children and how I raised them.

—It’s not about you.

Now, go share your actions with the person in the mirror and your loved ones, how to act when you don’t get your way.

It’s chicken-****, and it’s unprofessional, and demonstrates your lack of character.

Dr. *** (ED Director), I thank you for every minute of every hour of every day that you have endured as the director of this emergency room, under such incredible pressures.

…and my name is Joe ***, MD."


This is the problem of division we face in Emergency medicine.
Did that guy eat his words after the tail coverage disappeared ?
 
What a colossal ass. That email would make the likelihood of me showing up to shift even less. You and the medical director can absolutely get wrecked. I wouldn’t be able to look at myself in the mirror knowing I was being taken advantage of that badly. That’s called having self-worth, not whatever lame “I represent my alma mater” bull**** that guy has deluded himself with.
 
Here's a thought experiment for you to answer.

Suppose your group said there was a "problem" and your check was delayed by one month.

What do you do?

Stop working? If you credential elsewhere you're still a month+ out from getting another check.

I mean I don't support it either but I've not been in this situation and I could probably be convinced to string along in hopes all goes well eventually rather than credential elsewhere.
I have real insight into our finances. I would also consider how far out I knew. I would want a real reason as to why. The NES excuse was a stupid one and seemingly came just before payroll whilst in their messaging claims this has been ongoing for months and there had been chatter at least 4 months prior that they were having real financial issues.

So the answer isnt simple. They better lay bare some facts before i showed back up. I can get credentialed at a desperate site pretty quickly.
 
There's a difference between being employed vs. being self-employed in an SDG. If your employer is to the point that it can't meet payroll (meaning they've already exhausted all their lines of credit, etc.) then that company is done for and you should find another job immediately and quit working for free. This extends to basically any industry.
@AlmostAnMD Let me say my group through covid and other issues has had some rough months. Never did we miss payroll. The partners maybe took a hit.. thats the reality of being a real owner in a business. When things are good we do well when it is lean we suffer. When my group got COVID money the owners shared it. The MLPs didnt..
 
That older doc's email is a big ASS. If he is so altruistic, I hope he is still in month 3 working for free. If not, he is just a big hypocrite.

Unless you are the Captain and you know its going to sink no matter what you do, best to be the first off. The hospital system has lots of $$$ and can do emergency funding like they do with all other specialist that requires emergency coverage.
 
Here's a thought experiment for you to answer.

Suppose your group said there was a "problem" and your check was delayed by one month.

What do you do?

Stop working? If you credential elsewhere you're still a month+ out from getting another check.

I mean I don't support it either but I've not been in this situation and I could probably be convinced to string along in hopes all goes well eventually rather than credential elsewhere.
I have another place I already work.
 
I have another place I already work.

Honest answer is depends on my history with that job.

If it’s a great job I would give the employer/hospital system 2-3 days to make it right (check deposited) while showing up for shifts in this time window. This is what I would do with my current job.

If it was a straw that broke the camel’s back type situation and I already hated the job, goodbye.

In EITHER situation, I am finding other employment immediately. This includes getting credentialed, even if in scenario A they do make things right by depositing missing paycheck. At that point the writing is on the wall, and to not be credentialed somewhere else would be incredibly stupid.
 
Did that guy eat his words after the tail coverage disappeared ?
So it's kinda funny- the hospital has been obviously taken over/absorbed by another group; both that guy and the site director have sent emails to the new group and the hospital politely pleading/demanding they cover the tail coverage for the docs. Not holding my breath or even dipping a toe in that water and no reply yet that I'm aware of. And yea, I sorta liked him, but yea he is/was also kind of an ass. He was meant to retire a few months back. He remains the only guy I know who'd wear a tie, tie pin, and pressed shirt to shift every time and brag about rectally disimpacting 2 or 3 patients every shift. Never donned a gown. I always wondered about his dry cleaning bill or if alternatively he never washed those shirts and ties and just had perfect hands for the job. I'm not kidding. He once refused a signout for constipation after an enema pending bm and ride because I hadn't disimpacted them (remains the only one I've done as an attending with a decade of experience). I mentioned this latter on to the nurses and one of them said "Oh yeah, he and another doc in the group used to put everything they pulled out on a chuck and weigh it on the neonatal scale" as if they were competing for the king of crap high score. I imagine they never considered neonatal cross contamination and sort of wondered what the joint commission would say. Things I've considered when it's quiet at 2am. It's been a short and odd career.
 
Looks like the newest update on this ****ty situation. From reddit, it looks like NES has declared chapter 7 bankruptcy. From the reddit thread, all the doctors are SOL. They got misclassified as 1099 so will be at the back of the line for bankruptcy (aka, $0). Doctors forced to pay their own tail coverage was getting quoted up to 55k.

The lesson is get the **** out at the first check not clearing (if it wasn't already exceedingly obvious at the very beginning). The doctors who kept working kept holding a bigger and bigger bag of unpaid liability.
 
Yep..
Looks like the newest update on this ****ty situation. From reddit, it looks like NES has declared chapter 7 bankruptcy. From the reddit thread, all the doctors are SOL. They got misclassified as 1099 so will be at the back of the line for bankruptcy (aka, $0). Doctors forced to pay their own tail coverage was getting quoted up to 55k.

The lesson is get the **** out at the first check not clearing (if it wasn't already exceedingly obvious at the very beginning). The doctors who kept working kept holding a bigger and bigger bag of unpaid liability.
Yep. People can say they are misclassified as 1099 but there will be plenty of people who will espouse (and i dont fully disagree) with the benefirs of 1099. My 2 cents is that EM docs want their cake and to eat it too. They want the tax advantages of 1099 but then get mad if they are removed from the schedule. Perhaps they need a lesson on what being an IC means (good and bad).

In the end I feel for the EM docs who got screwed. That being said if they didnt learn from APP there is a saying..

Those who dont learn from history and doomed to repeat it.

One of my colleagues was left holding a 50K+ bad when app folded up.. Med mal coverage wont come cheap for them to just carry your tail.
 
1099 or W2. If they don't have money to pay, they don't pay. They are not paying for tail either way. The higher ups have taken their piece, and good luck getting anything through bankruptcy and years in courts.
 
Looks like the newest update on this ****ty situation. From reddit, it looks like NES has declared chapter 7 bankruptcy. From the reddit thread, all the doctors are SOL. They got misclassified as 1099 so will be at the back of the line for bankruptcy (aka, $0). Doctors forced to pay their own tail coverage was getting quoted up to 55k.

The lesson is get the **** out at the first check not clearing (if it wasn't already exceedingly obvious at the very beginning). The doctors who kept working kept holding a bigger and bigger bag of unpaid liability.

As perfectly stated in the reddit thread:

"The delay's most likely purpose was for the owner to collect revenue from the work done by those unpaid physicians, estimated at $30,000,000."

The "ra ra let's go team, my promise to cover a shift is a promise, let's all work for free" email above doesn't seem like it's aging well.....

Not EM but I've always said this about any job, the day the stop paying your paycheck is the day you stop showing up to work...cause then who's making money from the work you're doing that day? Spoiler alert, not you.
 
I stand by that I would work one more shift and if payment/solution isn't found, I am not showing up. The hospital can jump in and promise payment.

What really sucks it 50K for tail sucks. You got to buy it too.

Word to the wise. If you smell smoke, there likely will be fire. Look for an exit before having to hold the bag of poop.
 
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1099 or W2. If they don't have money to pay, they don't pay. They are not paying for tail either way. The higher ups have taken their piece, and good luck getting anything through bankruptcy and years in courts.
They have money.. most bankrupt businesses have assets. an employee and their wages rank pretty high up on the order of getting paid. 1099s not so much.

The issue is NES owners got that $30m and not their creditors nor the 1099 employees.

you know who else gets paid in a bankruptcy? The bankruptcy lawyers. So there is def money.
 
I'm increasingly convinced that there's no Democrat or Republican, just money and who is willing to be bought.

A lot of this PE in healthcare stuff was done while Democrats in my state were in power. Was propagated nationally with both Republicans and Democrats in power.

We get screwed either way. Meanwhile the plebs fight about who can use what bathroom.
 
Learn to be an owner and Boss so you can make decisions. If you are a 1099 or W2 army ant, you will get crushed when you are not needed anymore or the bosses/owner decided they have squeezed all the juice that they can.

It is life. If you do not make decisions, you have very little job security.
 
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