NYT article on EmCare

[deleted109597]

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[Siggy]

Gee, if only there was a set rate that all the hospitals charged for each service they provided and that everyone's insurance was accepted everywhere cough*singlepayer*cough.

So basically you want to put hundreds of thousands of honest, hard working, health insurance workers out of work? [/devil's advocate] [/sarcasm]

 

[doctalaughs]

So basically you want to put hundreds of thousands of honest, hard working, health insurance workers out of work? [/devil's advocate] [/sarcasm]

I agree single payer may be the only endgame when this house of cards collapses.

Not that it will be good for physicians. You'll get the low reimbursement like in other single-payer systems, coupled with the faults of the US system-- double the work hours, double the paperwork, litigious, high-liability, 6-figure educational debt, obese, entitled population.

We will become one of the worst places to practice medicine among 1st world nations. At least with the crap not present in other countries we are paid fairly well now. If that goes away who's gonna want to be a doctor? Hopefully I will be out by then.


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[Angry Birds]

I agree single payer may be the only endgame when this house of cards collapses.

Not that it will be good for physicians. You'll get the low reimbursement like in other single-payer systems, coupled with the faults of the US system-- double the work hours, double the paperwork, litigious, high-liability, 6-figure educational debt, obese, entitled population.

We will become one of the worst places to practice medicine among 1st world nations. At least with the crap not present in other countries we are paid fairly well now. If that goes away who's gonna want to be a doctor? Hopefully I will be out by then.


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As a liberal/progressive I do think single payer is good for America as a whole.

As a physician, I think it would be absolutely horrible for us. I do think we deserve the current salary we have based on all our advanced education and hard work.

 

[GeneralVeers]

I agree single payer may be the only endgame when this house of cards collapses.

Not that it will be good for physicians. You'll get the low reimbursement like in other single-payer systems, coupled with the faults of the US system-- double the work hours, double the paperwork, litigious, high-liability, 6-figure educational debt, obese, entitled population.

We will become one of the worst places to practice medicine among 1st world nations. At least with the crap not present in other countries we are paid fairly well now. If that goes away who's gonna want to be a doctor? Hopefully I will be out by then.


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Right. If I wanted to work in a country that has nationalized health, I'd go to Australia. (yes I know they have private insurance and hospitals too)At there we still can get decent salaried, without being tormented by all the administrative and liability crap in this country.

 

[sum dude]

You don't have to work for that hospital. Your skills are in demand - if you vote with your feet, you can get a fair contract. They can't run a hospital without an ED...

That's a naive position. Many people live in areas dominated by one hospital system. Further, if a hospital says it's "In-Network" but none of its doctors are, it's not really in network, is it?

For all those defending SDG's, you don't realize the biggest threat is not CMG's, but rather insurances. If they ban Balance billing in your state, the EMCare's of the world are going to smoke the small, independent SDG's out of the water in contracts and collections. They get much better rates out of their In-Network groups b/c of their bargaining power, and b/c of their collections, they can aggressively bill OON providers (which, in state's where Balance Billing is not banned, then use that for leverage for even better In-Network rates). EMCare skins a lot of money off their docs, and they put that money into their billing and collections--even without fraud, they're going to collect better than a small group in Eastern Washington.

If you work for a competitive SDG, it's probably b/c you are able to collect a solid amount out of Network, which pays better. The insurances figured this out, hence hit pieces like this, by their paid Yale shill, Zack Cooper, whose research they bankroll. The insurances started running these hit-pieces 7 years ago, and are winning the balance billing wars in places like Illinois and Florida. What many EM docs don't realize is that Balance Billing is the only leverage a 100 person group has against United, Aetna, Anthem, etc.

The only hope for our specialty (especially non-CMG groups) is fighting the insurances, and coming up with fair compromises like Connecticut did in getting 80% of Usual and Customary Charges per FairHealth. ACEP has done a much better job fighting this than AAEM, though in truth, they should be working on this together to fight the multi-trillion dollar insurance industry. As Ectopic explained above, all our salaries are paid by about 30% of our commercial carriers--we are extremely sensitive to any changes in commercial reimbursement. FWIW, the data in the NYT article was provided by one carrier--you think there's any conflict of interest there?

 

[sum dude]

Here's the best or possibly lamest way I can explain it to the docs who aren't getting it:

The insurances are the White Walkers
EmCare is the Lannister army.
AAEM is getting ready to fight the Lannisters, while the White Walkers are coming to destroy their souls.
ACEP is like the North--flawed, outnumbered, split on who to fight.

The White Walkers are the bigger enemy

 

[bravotwozero]

So you're explaining it with references nobody is familiar with?


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[doctalaughs]

So you're explaining it with references nobody is familiar with?


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Hey - if you don't watch the best show ever made on television that's your loss...


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[bravotwozero]

Au contraire, I don't watch television, in fact I don't even have a TV (by choice) - my gain!


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[NYEMMED]

Here's the best or possibly lamest way I can explain it to the docs who aren't getting it:

The insurances are the White Walkers
EmCare is the Lannister army.
AAEM is getting ready to fight the Lannisters, while the White Walkers are coming to destroy their souls.
ACEP is like the North--flawed, outnumbered, split on who to fight.

The White Walkers are the bigger enemy

I would say ACEP is like Theon, disappears when you need him

 

[doctalaughs]

Au contraire, I don't watch television, in fact I don't even have a TV (by choice) - my gain!


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Buy a 1 month subscription to hbonow for 20 bucks and binge watch game of thrones on your ipad. You won't regret it.


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[Angry Birds]

Au contraire, I don't watch television, in fact I don't even have a TV (by choice) - my gain!


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I call bulls** whenever anyone says the words "I don't have a television." Yes you don't have a television but you have Netflix, Hulu, Amazon Instant, etc. That's television.

People love announcing their lack of a tv just like vegans like announcing their veganness.

 

[bravotwozero]

I call bulls** whenever anyone says the words "I don't have a television." Yes you don't have a television but you have Netflix, Hulu, Amazon Instant, etc. That's television.

People love announcing their lack of a tv just like vegans like announcing their veganness.

Have none of the above - prefer reading good books. You should read amusing ourselves to death and four arguments for the elimination of television....


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[doctalaughs]

Have none of the above - prefer reading good books. You should read amusing ourselves to death and four arguments for the elimination of television....


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Hey - whatever floats your boat man. But don't pretend something is an obscure reference no one gets when the rest of the country did.

I also enjoy a good book and only religiously watch about 1 TV series every 5 years but that one is worth it. It's well done especially if you are the sort that enjoys sci-fi type genres.


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[Angry Birds]

Have none of the above - prefer reading good books. You should read amusing ourselves to death and four arguments for the elimination of television....


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Mann, my apartment is full of books.. I'm a ferocious reader. But seriously, how do you spend time with the wife? "Hey honey, let's read a book together." Nerd.

I feel like stealing your lunch.

 

[EctopicFetus]

Insurance is evil. The system is corrupt and Ill say this simply, if you set foot into an Emcare or Team job for under $300/hr you are screwing your self.

For those who support the single payer system keep in mind that without pouring MORE money into the system than now hospitals would shut their doors. Hospitals can not afford to stay open in all their payments were medicare payments.

The other issues with single payer is the government dictates all and can cut pay by 20% without any recourse.

In the end EMcare sucks, I am dropping my acep membership this year, I urge you all to do the same. Let ACEP hit emcare and TH and USACS for more money.

Supporting ACEP is supporting your own demise.

I have been an aggressive saver and have had some good luck. Im not 40 and I could retire today if I cut my lifestyle ever so slightly. I will be able to retire like a king in 10 years. All you young pups out there heed this advice.

1) live like a resident and work like a dog when you get out and pay off your loans at no less than 10k per month.
2) save 20% minimum of your income (pre tax). If you earn 400k save 80k.

Do this and before the excrement hits the fan you will have options.

For those who want to keep playing the acep game ask yourself what you are getting for you money. For me it is clear it isnt much. Better to be with 8,000 like minded people in AAEM fighting the good fight than joining the majority being eating from the inside out without even knowing it.

Last ACEP number was 31k. Thats groups where you dont have a choice to join or not and residents I am sure. They are killing us by not fighting the violations of the corporate practice of medicine and not opposing the illegal union of HCA and Emcare. You can vote with your money. I know I will.

 

[deleted859535]

Less than $300/hr, eh.

I'm more in the low $200/hr range. SDG. Good benefits, though.

Guess my ideology is costing me ~$50/hr on average... until partnership, maybe.

 

[GeneralVeers]

Guess my ideology is costing me ~$50/hr on average... until partnership, maybe.

LMAO......until partnership. You will be working for EmCare or Teamhealth long before you make partner.

 

[TooMuchResearch]

LMAO......until partnership. You will be working for EmCare or Teamhealth long before you make partner.

No market penetration by them here, 0%, and our SDG is expanding. I'll remain optimistic for now as the partners benefit from my efforts. If it doesn't pay off, oh well, I took a risk and took the job I wanted. I can always jump on the locums bandwagon if need be.

 

[GeneralVeers]

No market penetration by them here, 0%, and our SDG is expanding. I'll remain optimistic for now as the partners benefit from my efforts. If it doesn't pay off, oh well, I took a risk and took the job I wanted. I can always jump on the locums bandwagon if need be.

I was wrong. It won't be EmCare. Your "expanding" group will just get bought out by USACS/Blackrock. Just look at ESP in Texas, FEP in Florida, or Tampa Emergency physicians.

 

[thorg12]

Veers and toomuch,
I applaud you for joining a sdg.
I think we should be encouraging prepartners in sdg groups, as long as they are not predatory and are transparent.
I truly believe the remaining small honest democratic groups are the key to our survival as a specialty; especially in markets where the population has private insurance.

 

[deleted859535]

Veers and toomuch,
I applaud you for joining a sdg.
I think we should be encouraging prepartners in sdg groups, as long as they are not predatory and are transparent.
I truly believe the remaining small honest democratic groups are the key to our survival as a specialty; especially in markets where the population has private insurance.

I assume you meant @TooMuchResearch and I. Don't think Veers is a SDG guy. Similar to TMR, my area is one of SDGs -- but the CMGs are knocking and have been for awhile. Much as he said, if my group is bought out before I'm a partner and thus stand to profit from it anyway, well, there are worse things. Took a risk for a group I like in a hospital system I like.

Think I read something on this site at one point comparing CMGs and the higher up front hourly rates on average to using crack.

 

[WilcoWorld]

Insurance is evil. The system is corrupt and Ill say this simply, if you set foot into an Emcare or Team job for under $300/hr you are screwing your self.

For those who support the single payer system keep in mind that without pouring MORE money into the system than now hospitals would shut their doors. Hospitals can not afford to stay open in all their payments were medicare payments.

The other issues with single payer is the government dictates all and can cut pay by 20% without any recourse.

In the end EMcare sucks, I am dropping my acep membership this year, I urge you all to do the same. Let ACEP hit emcare and TH and USACS for more money.

Supporting ACEP is supporting your own demise.

I have been an aggressive saver and have had some good luck. Im not 40 and I could retire today if I cut my lifestyle ever so slightly. I will be able to retire like a king in 10 years. All you young pups out there heed this advice.

1) live like a resident and work like a dog when you get out and pay off your loans at no less than 10k per month.
2) save 20% minimum of your income (pre tax). If you earn 400k save 80k.

Do this and before the excrement hits the fan you will have options.

For those who want to keep playing the acep game ask yourself what you are getting for you money. For me it is clear it isnt much. Better to be with 8,000 like minded people in AAEM fighting the good fight than joining the majority being eating from the inside out without even knowing it.

Last ACEP number was 31k. Thats groups where you dont have a choice to join or not and residents I am sure. They are killing us by not fighting the violations of the corporate practice of medicine and not opposing the illegal union of HCA and Emcare. You can vote with your money. I know I will.

Liked by Wilco World, FAAEM

 

[EctopicFetus]

The SDGs have to be fair. Part of this is a problem of our own creation but when the new grads take crap emcare jobs it is a death spiral.

 

[Arcan57]

Veers and toomuch,
I applaud you for joining a sdg.
I think we should be encouraging prepartners in sdg groups, as long as they are not predatory and are transparent.
I truly believe the remaining small honest democratic groups are the key to our survival as a specialty; especially in markets where the population has private insurance.

HSDGs are not the key to our survival as a specialty. There are too few of them and too many imitators that look like HSDGs but aren't. The deal that CMGs offer up front is too good to pass up without a significant change in mindset from new grads. Many EM people went into the specialty because it's one of the closest things to instant gratification that medicine offers. We have a short residency and we come out expecting immediate equality with everyone else in the field in both pay and schedule. Most other specialties are grinding harder their first years out then they were in residency, we're already planning how to cut back. And so the CMGs oblige us with jobs that meet those expectations. It's what the marketplace wants.

The real key to our "survival" as a specialty is not to take crap jobs. Educate yourself on what you and your colleagues are billing and have some idea of the payor mix and how much is actually being collected. If you're in a crap job, demand more money or leave for a better job. If you're making way below market rate, make sure it's at a job where you're seeing <1pt/hr in a non-malignant environment in a location you want to be in.

 

[thorg12]

HSDGs are not the key to our survival as a specialty. There are too few of them and too many imitators that look like HSDGs but aren't. The deal that CMGs offer up front is too good to pass up without a significant change in mindset from new grads. Many EM people went into the specialty because it's one of the closest things to instant gratification that medicine offers. We have a short residency and we come out expecting immediate equality with everyone else in the field in both pay and schedule. Most other specialties are grinding harder their first years out then they were in residency, we're already planning how to cut back. And so the CMGs oblige us with jobs that meet those expectations. It's what the marketplace wants.

The real key to our "survival" as a specialty is not to take crap jobs. Educate yourself on what you and your colleagues are billing and have some idea of the payor mix and how much is actually being collected. If you're in a crap job, demand more money or leave for a better job. If you're making way below market rate, make sure it's at a job where you're seeing <1pt/hr in a non-malignant environment in a location you want to be in.

Except new grads don't know what crap jobs are bc they don't know what is billed and collected in their name.
Groups that show this stuff and are transparent.
This allows prospective employee to say yes I think the amount the group takes off the top seems fair or not.

 

[EctopicFetus]

Less than $300/hr, eh.

I'm more in the low $200/hr range. SDG. Good benefits, though.

Guess my ideology is costing me ~$50/hr on average... until partnership, maybe.

As a non partner there is a buy in. You are working toward something. As an Emcare employee you simply fund their parties and playboy lifestyles.

 

[GeneralVeers]

SDGs have made themselves obsolete with the "buy-ins". I would never take an SDG job these days regardless of the promises made. There is simply too much risk. Why make a low hourly for 2 years, with a high chance of the practice being sold, or not making partner in 2-3 years? Also having to pay $250,000 buy-in to become partner is risky, when the practice can get sold by the senior partners at any time. If I can make $300+ out of the gate working with a CMG, it seems like much more of a sure thing.

SDGs need to eliminate buy-ins, and low initial hourlies if they want to compete. The old fashioned pyramid scheme setup is not longer going to work, and top level partners are going to have to give up something. Theoretically if a large percentage of collections isn't going to the CMG (in Vegas it is 20% + expenses) they should be able to offer a competitive or superior initial hourly rate to what a CMG offers. To promote longevity at the site they should offer annual bonuses for completing 1 year, plus an extra bonus every 5 years with the group.

 

[EctopicFetus]

So to your point when I left my last SDG I looked at 2 other SDGs. The main reason I picked the one I did was 1) stability and 2) low buy in.

I picked right cause my other option went the way of the DODO bird as our friends at USACS screwed these guys in the ESP deal.

I think the days of ultra low initial pay are gone and the risk in this environment is way too high to be stuck doing that bs.

 

[bravotwozero]

There are also local/regional physician owned CMGs - I work for one, and have found them to be pretty fair - you may not make 300/hr, (though I'm not too far off that mark at times), but you'll certainly make above market rates, as many of these groups don't shell out money for fancy ACEP parties or need to pay travel expenses for interviewees. If no reasonable SDG in your area, you may be better off with such a group than working for your mega corporate CMG.


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[GeneralVeers]

There are also local/regional physician owned CMGs - I work for one, and have found them to be pretty fair - you may not make 300/hr, (though I'm not too far off that mark at times), but you'll certainly make above market rates, as many of these groups don't shell out money for fancy ACEP parties or need to pay travel expenses for interviewees. If no reasonable SDG in your area, you may be better off with such a group than working for your mega corporate CMG.


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Hmm....if they don't shell out money for parties or travel expenses, and aren't paying over $300/hour then it's not fair. They are billing $1000/hour in your name, so someone is keeping a lot of money.

 

[bravotwozero]

The location I work for has a pretty crummy payor mix, with a good number of patients (possibly 30%?) being self pay, so I don't know if they can really get up to $1000/hr there...


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[GeneralVeers]

The location I work for has a pretty crummy payor mix, with a good number of patients (possibly 30%?) being self pay, so I don't know if they can really get up to $1000/hr there...


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It should be law that CMGs reveal the actual dollar amount collected in our name on a monthly basis.

 

[deleted109597]

It should be law that CMGs reveal the actual dollar amount collected in our name on a monthly basis.

I mean, I can go look up what was billed in my name for CMS. Why not for everything?

 

[GeneralVeers]

I mean, I can go look up what was billed in my name for CMS. Why not for everything?

Right. From there it should be a simple math problem of figuring out your hours per month to get a rate. If you are 1099, assume an overhead of 10-15%

Reasonable profit for a CMG should be 10%. So math should be (Total collected - overhead)*0.9 = hourly for physician.

 

[TooMuchResearch]

I was wrong. It won't be EmCare. Your "expanding" group will just get bought out by USACS/Blackrock. Just look at ESP in Texas, FEP in Florida, or Tampa Emergency physicians.

Could be. Again, no market penetration here, and the group values Independence. The varied age of the partners and ownership structure should help protect against buyout. There are still good jobs that don't involve working for the man.

 

[GeneralVeers]

Right. From there it should be a simple math problem of figuring out your hours per month to get a rate. If you are 1099, assume an overhead of 10-15%

Reasonable rate for a CMG should be

Could be. Again, no market penetration here, and the group values Independence. The varied age of the partners and ownership structure should help protect against buyout. There are still good jobs that don't involve working for the man.

No market penetration puts you at more risk. USACS had zero market penetration in Texas for 20 years (including EMP). They saw that as a shortcoming, so bought out ESP to get market share.

 

[deleted109597]

I don't know that anything you protects you. Look at Summa and the residency program. Look at literally every other group being bought out. If the grass truly is greener where you are, that makes you more of a target to them.
I mean, keep fighting the good fight, but have a parachute.

 

[naus]

There's rampant overbilling in the ED with EMRs and templates. I've seen my share of obvious isolated ankle fractures being billed as a level 5 when the only MDM is an ortho consult after radiology calls the ED physician. This kind of abuse will only lead to more midlevel encroachment as even monkeys can bill for level 5s.

 

[southerndoc]

There's rampant overbilling in the ED with EMRs and templates. I've seen my share of obvious isolated ankle fractures being billed as a level 5 when the only MDM is an ortho consult after radiology calls the ED physician. This kind of abuse will only lead to more midlevel encroachment as even monkeys can bill for level 5s.

If they get an IM/IV injection of a controlled substance for pain, isn't it automatically a level 5? CMS considers parenteral administration of opiates to be high-risk.