What EM employee model are you working?

  • CMG

    Votes: 6 30.0%
  • Democratic and/or Independent Group

    Votes: 4 20.0%
  • Hospital Employee

    Votes: 7 35.0%
  • Other

    Votes: 3 15.0%

  • Total voters
    20

Groove

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Which ones do you guys prefer? My current contract was with a CMG that imploded and now they are forcing hospital employee status on the EPs. No more IC, etc.. The pitch was the benefits of employe status with maintaining IC level of salary. Personally, I don't think it's sustainable.

I prefer IC, but sometimes I wonder if hospital employee model is better? It seems you have less autonomy, obvious tax disadvantages but dance to the strings of hospital administration who can change policy at whim.

Has anybody had good/bad experiences throughout your career that you mind mentioning?

Right now, I'm single, no kids, need less benefits and want to enjoy the tax advantages of IC status that seems to afford me a greater level to pay down debt and invest. I know CMGs skim off my paycheck, but somehow I'm philosophically more aversive to being in a private democratic group on a 2yr partnership track where it's my colleagues and friends who are skimming off me along with feeling pressured to keep everyone happy, work all the hard shifts, and risk 2 yrs in loss of salary in the hopes that I'll make partner (and more importantly...want to stay there.). I much prefer to hit the ground on the same playing field that I enjoy as an IC for a CMG. Maybe I'm being unrealistic. I also don't like the strings that go along with private groups that would keep me tied in one place unless I were convinced that I was ready to settle down semi-permanently in a single area.

I'm essentially giving up a hospital employee model to take a job as an IC again with a CMG. Part of me wonders if I'll regret the decision.
 
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GeneralVeers

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I am currently an IC employed by the hospital. It is far superior and more enjoyable than working at a parasitic CMG.
 

RustedFox

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I am presently employee at a big CMG.

Hate the oversight, and the fact that every decision is made by people who have never worked a day in the department.

Love the fact that as an employee, I get health insurance (see other recent posts about being denied, period) thus IC wasn't an option for me.

The game has changed.
 

Janders

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Not all private groups are pyramid schemes that keep their young non-partners on a minimal salary for 2-3 years for the POSSIBILITY of becoming partner.

For example, my group... which is democratic, open-book, low-overhead where you eat-what-you-kill at the same rate as everyone else starting on your first day. Great model. Very fair. We are paid via W2, not IC... but we do put a ton of money into retirement from the employer side, pretax... which is nice.
 
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Where I'm headed is similar to Janders. Democratic, open book, eat what you kill where newbies make the same as the old timers. This model takes the percent that you bill from that of the group for the month and then gives you the same percent of total monthly compensation for that month minus the overhead. IC status. States they never need to pay the base but have a minimum of 20k per month base for FTE.
 

The White Coat Investor

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I'm surprised to hear people defending the employee and CMG model. I view it as so inferior that no one would take it unless they had to in order to live in their desired location. We have a two year partnership track. You still make 4 times as much as you did as a resident during those two years and you don't work any more hard shifts than anyone else. Books are open to you and honestly, although you don't believe it at the time, it's pretty clear if you're going to make it after 3 months and if you're not we cut you loose early. If you're meeting with several partners every 3 months and they're telling you there are serious things you need to change, then you've got a problem.

Not only do I get paid a heck of a lot more than an employee, but I also get a lot of say in everything. Who we use for malpractice insurance, how our shifts are staffed, who we hire, who we fire, how we interact with other departments etc. Only as a partner are you really aware of just how much moola the CMGs and hospital employers are really skimming. I see the Daniel Sterns survey every year about how an average employee makes $150 an hour. Well, I guess if you're willing to give up 25-50% of your take home for the "conveniences" of being an employee, well, knock yourself out. I'd rather have a little less predictable cash flow, deal with some minor annoyances of being my own boss, and have the freedom to shape my job and make a lot more money. I don't know if we can fend off the CMGs forever, but we're going to do it for as long as we can.
 

docB

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I prefer IC, but sometimes I wonder if hospital employee model is better? It seems you have less autonomy, obvious tax disadvantages but dance to the strings of hospital administration who can change policy at whim.
Why does being an IC give you more autonomy than being an employee? Both ICs and employees are slaves to the whims and strings of the hospitals with their wacky policies, metrics and whatever the critical hot-button issue of the day is. They both are always at risk of the nuclear option, pulling the contract. It also doesn't matter if it's a CMG or an Indie Demo group, anyone can lose their contracts no one can tell the admins to shove it when they demand something.

I currently work both as a W2 employee and an IC for a CMG (long story). There are tax advantages to being an IC BUT you need to know what you're doing and most of us need to have a good accountant to actually realize the advantage. If you're more of a financial novice you will probably do better as an employee if you get some benefits.

One thing about "eat what you kill" arrangements. It's really important to know if your set up considers "what you kill" as your billing or your collections. If you get credited based on your billing then all the money the group collects goes into a pool and you each get paid based on how many RVUs you generated. If it's based on your collections then you get paid whatever money your patients and their payers send in. The difference is that a billing based model spreads the risk (or cost) of seeing the uninsured over the whole group and you're more assured of getting paid something every month. If it's based on collections then you could see a big drop in your income if you are unlucky and see a lot of uninsured in a month. A collections based model also frequently causes "cherry picking" where docs try to pick up the old people on Medicare and avoid the homeless. Imagine if you show up to start a shift and your partner has picked up all the nursing home transfers but left the bums for you. You'd be working for free (actually paying to work) for the first few hours. Cherry picking can also extend to shifts. Certain shifts can be notorious for seeing a worse payer mix, e.g. Friday and Saturday nights.
 

Janders

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One thing about "eat what you kill" arrangements. It's really important to know if your set up considers "what you kill" as your billing or your collections. If you get credited based on your billing then all the money the group collects goes into a pool and you each get paid based on how many RVUs you generated. If it's based on your collections then you get paid whatever money your patients and their payers send in. The difference is that a billing based model spreads the risk (or cost) of seeing the uninsured over the whole group and you're more assured of getting paid something every month. If it's based on collections then you could see a big drop in your income if you are unlucky and see a lot of uninsured in a month. A collections based model also frequently causes "cherry picking" where docs try to pick up the old people on Medicare and avoid the homeless. Imagine if you show up to start a shift and your partner has picked up all the nursing home transfers but left the bums for you. You'd be working for free (actually paying to work) for the first few hours. Cherry picking can also extend to shifts. Certain shifts can be notorious for seeing a worse payer mix, e.g. Friday and Saturday nights.
We are eat-what-you-collect. However, you don't see a month-to-month variation in your income. Instead, our business guy runs the numbers, estimates what you will collect for the year, and pays that out as a salary every 2 weeks. He underestimates slightly. Then every quarter we reconcile your actual collections vs. your costs. You get the difference paid out as a bonus. That way you have a steady, even paycheck to count on, but still get every $$$ you generate once overhead is skimmed.

What I like about our model:
-- Huge % of money goes to the doc who actually did the work, not the middle man.
-- Hence very competitive salary
-- I prefer productivity based pay... I'm productive! It also keeps me working hard and makes those busy shifts seem a little sweeter.
-- We make decisions as a group. How many PAs? Do they only get fast-track? How should we split shifts? 8hr? 9hr? etc.
-- We can be creative as we want with our money. Old guys don't want to work nights? Create a night shift tax, with a $ amount everyone agrees to. We did.

I agree with docB, there is the potential for abuse. However, to be blunt, we simply wouldn't put up with a member of the group grossly cherry picking based on insurance status. Sometimes you get an unlucky shift with a lot of "selfpays" but that should average out in the end. Besides, in MA, there are not THAT many selfpays left ;)
 

docB

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We are eat-what-you-collect. However, you don't see a month-to-month variation in your income. Instead, our business guy runs the numbers, estimates what you will collect for the year, and pays that out as a salary every 2 weeks. He underestimates slightly. Then every quarter we reconcile your actual collections vs. your costs. You get the difference paid out as a bonus. That way you have a steady, even paycheck to count on, but still get every $$$ you generate once overhead is skimmed.

What I like about our model:
-- Huge % of money goes to the doc who actually did the work, not the middle man.
-- Hence very competitive salary
-- I prefer productivity based pay... I'm productive! It also keeps me working hard and makes those busy shifts seem a little sweeter.
-- We make decisions as a group. How many PAs? Do they only get fast-track? How should we split shifts? 8hr? 9hr? etc.
-- We can be creative as we want with our money. Old guys don't want to work nights? Create a night shift tax, with a $ amount everyone agrees to. We did.

I agree with docB, there is the potential for abuse. However, to be blunt, we simply wouldn't put up with a member of the group grossly cherry picking based on insurance status. Sometimes you get an unlucky shift with a lot of "selfpays" but that should average out in the end. Besides, in MA, there are not THAT many selfpays left ;)
All great points. The fact that the pay vs. no pay should all even out over time is certainly true.

I really like our set up with pay based on billing (RVU generation) rather than collections. This system is just as productivity based as the other way. We also make decisions like MLP staffing, hours, shift differential and so on.
 

Janders

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Yeah frankly the differential between RVU and collections should be nil with a large enough sample size and long enough time frame to even out the random no-pays, medicaids, etc.
 

TrumpetDoc

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New gig is really nice. Small democratic group. No buy in.

Paid as IC. Group gives essentially a salaried amount per month and remainder of groups profits given out at year end as bonus.
Was with big CMG before. So much nicer having control of my own finances. And, to be honest, my new hospital actually cares what the ED docs think and really loves the group.
I also moonlight at a hospital employed place and man...they have it good there too!
 

pagemmapants

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Salary-only (No RVU component to compensation) democratic multi-specialty (but EM majority) group with partnership with a significant buy-in at 2 years; buy-in nets you shares in both the group and the actual hospital. Full benefits. Same proportion of nights/weekends no matter your seniority (including pre-partners). It's a unique setup.

I only interviewed at democratic groups. Others I looked at were mostly EM-only democratic practices with flat organizational structures. They mostly did have more nights and weekends, as well as higher shift requirements for the n00bs; but those without significant stock benefits for partners had minimal buy-ins (i.e. $1 at one particular place). Generally the wait for partnership was at least 3 years OR XXXX hours, whichever came second.

As a resident I moonlighted with a CMG. I knew I wanted to be invested in a partnership due to the relationships that you develop and the inherent interpersonal accountability, as well as a higher standard of/acceptability of patient turnovers. At the CMG I worked with moonlighting the mentality was sort of "you stay until your patient's are dispo'd, even if that is 2 hours after your shift ends, unless you have NOTHING left but 1) one patient awaiting CT to r/o something simple or 2) the usual stack of psych hold patients". And, lastly, I'm terrible at bureaucracy so I didn't want to have to expend the effort to research and obtain my own disability/health/malpractice insurances.

Re: salary only arrangement... I know a lot of very productive folks would really hate this sort of situation but I favor this because, as a new attending, I didn't want there to be 1) any consideration of finances when I decided which procedure and/or test to order on a patient, even subconsciously; 2) any temptation to cherry-pick because I already like orthopedic procedures enough without them being even more attractive due to billing considerations or 3) pressure either from myself or my pocketbook or my group to go faster than I felt comfortable. Here we're single coverage, so it doesn't matter anyway.