TheComebacKid

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A thought experiment, if you will... Just play along.

We all know things aren't headed in the right direction. This forum is full of great threads on topics related to midlevel expansion, the nefarious practices of CMGs, and the glut of garbage residency programs popping up everywhere.

I am guilty of this more than anyone, namely, complaining. That's not what this thread is about.

While many of the apathetic EM souls will say, "we are too far gone, the last shoe has already dropped", I would argue that the next 10 years are going to be critical to "save" our specialty, so to speak. I believe it can be done.

I recognize this is David vs. Goliath. I recognize the American health care system, the CMGs, insurance companies, are all working against us. But collectively, as a group of physicians, I believe we can steer our specialty away from from the inevitable iceberg.

Propose solutions, that we as individual physicians, can partake in. "Go into pain" or "Switch specialities" is not a solution. Perhaps a grassroots approach will work better.

Watch for inspiration:
 
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RustedFox

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Step 1: Replace ACEP with people who have actual souls instead of greedy toads.
Step 2: Tighten rules on residency credentialing with the RRC.
Step 3: ?????
Step 4. Profit (in the form of achieving the OP's goals)
 
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TheComebacKid

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I think the role of ACEP is probably one of the most critical parts of things turning around.

I've spent a lot of time in this forum bashing ACEP. I think most of it is warranted, because on many critical issues, they have failed to support EM physicians. There is an insane conflict of interest in that CMGs essentially own and throw money at ACEP, who then in turn lobbies on their behalf instead of on behalf of the physicians paying dues. It's why they have not unequivocally blocked the expansion of CMG sponsored residencies, or midlevel expansion for that matter.

While I love AAEM and what they stand for and in the past have encouraged people to support to them over ACEP, in the past few months I've thought about it quite a bit, and I came to the realization that AAEM just doesn't have the resources at this juncture to institute meaningful change on the scale that is required. They are on the right side of all the issues, but I get the sense that they write a lot of really great position statements that make feel all warm and fuzzy, but in terms of actual influence and policy change, they don't have the means to accomplish it like ACEP does.

Whatever change happens in our specialty, as much as it pains me to say, I think ACEP will likely be involved from an advocacy standpoint. So force their hand. Temporarily, don't pay dues and cite specific changes to your local ACEP chapter. Demand that they get out of bed with the CMGs. Demand that the president of ACEP does not work in the C-suite for Envision, or Team Health. There is absolutely no reason why any EM physician needs to attend the conference and collect free swag from TeamHealth or anyone else for that matter.

I think we need to turn up the pressure on ACEP.

Watch for further inspiration:
 
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turkeyjerky

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I joined AAEM today, coincidentally. I also read The Rape of Emergency Medicine over the weekend. What a great read, I can't believe it took me this long.
 
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Physicians as a whole need to be willing to stop working. The only negotiating tactic that matters is willingness and ability to walk.

Imagine a world where all EM physicians woke up one day and said "fuq this, I'm not going to work again until pay is x, and working conditions are y." The hospitals would shyt their pants and would cave immediately. The problem is, there are always a handful of rats who will keep working for pennies (Denver is down to $125/hr with U-SUCK lmao) and in dangerous working conditions out of some perverse "morality" or actual immediate financial need.

Physicians are notoriously awful with personal finance so this dream of mine will never happen. I could stop working today and be totally fine for a year or longer (and I have a kid). If only my colleagues realized they shouldn't:

-Have a 1 million dollar home which they pay 30k/yr in taxes on
-Send their kids to private school, when they are already paying a stupid amount of income/property tax
-Pay for their kids to have horses
-Have a new 50k+ car every 5 yrs
-Spend 30k on vacations every year

They could be financially free of the corporate world we live in.
 
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Physicians as a whole need to be willing to stop working. The only negotiating tactic that matters is willingness and ability to walk.

Imagine a world where all EM physicians woke up one day and said "fuq this, I'm not going to work again until pay is x, and working conditions are y." The hospitals would shyt their pants and would cave immediately. The problem is, there are always a handful of rats who will keep working for pennies (Denver is down to $125/hr with U-SUCK lmao) and in dangerous working conditions out of some perverse "morality" or actual immediate financial need.

Physicians are notoriously awful with personal finance so this dream of mine will never happen. I could stop working today and be totally fine for a year or longer (and I have a kid). If only my colleagues realized they shouldn't:

-Have a 1 million dollar home which they pay 30k/yr in taxes on
-Send their kids to private school, when they are already paying a stupid amount of income/property tax
-Pay for their kids to have horses
-Have a new 50k+ car every 5 yrs
-Spend 30k on vacations every year

They could be financially free of the corporate world we live in.

in WV not that long ago there was a physician strike until they reformed the malpractice climate.
 
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CajunMedic

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in WV not that long ago there was a physician strike until they reformed the malpractice climate.

Ironically, they told us about it the day my residency closed. It was in 2003, primarily around Wheeling and Weirton. PA was headed that same way, but their Governor managed to head it off.

Before we left, we recreated a photo that the 8 of the striking surgeons had taken, except it was 33 of us this time. IMG_2150.jpeg
 
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gomavs

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Love to see this. As a coming graduate of the class of 2021, I know things are tough first hand. I also know that there are times in life to stand up and take action. I think my peers are willing to do whatever we can to help. The question is, what do we do? Help the padawans help themselves, Oh Jedi Council.
 
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EctopicFetus

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I would love to see ACEP take a stand vs CMGs. Write letters to hospital CEOs telling them the perverse nature of PE backed companies. Floating the benefits of SDGs and gasp organizing local docs to kick out the CMGs and take over as SDGs. AAEM can do this too.

It can only be won an inch at a time. News today that envision lost a few contracts to some SDG in KC. Wins are popping up slowly but surely.

We have to be willing to organize locally and this is the hard part.
 
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Rekt

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I would love to see ACEP take a stand vs CMGs. Write letters to hospital CEOs telling them the perverse nature of PE backed companies. Floating the benefits of SDGs and gasp organizing local docs to kick out the CMGs and take over as SDGs. AAEM can do this too.

It can only be won an inch at a time. News today that envision lost a few contracts to some SDG in KC. Wins are popping up slowly but surely.

We have to be willing to organize locally and this is the hard part.

Agree, but we need to stop dancing around the issue. We need a direct opposition to residency expansion, similar to the multi-organizational letter against mid-levels/noctors, except even more severe, stating that expansion needs to be completely held until true workforce supply vs. demand can accurately be obtained. A large portion of stopping expansion will also hurt these CMG sweatshop residencies.
 
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Psych here...

1) Certificate of Need will have to be revoked in states that have them. Can't open your own hospital or ASC, then you are stuck with existing poor infrastructure inertia of controlling health systems that just don't care and see you as an expendable Provider who only does widgets.
2) Find other like minded physicians who also want to open up a new hospital. Have in the Bylaws 100% physician, and only physician. Advertise the heck out of being physician only.
3) Explore different hospital certification options in case anything nefarious exists with JCAHO; like that nordic shipping company that crossed over, or even the American Osteopathic Association, and I believe there might be 1-2 other hospital certification entities.
4) After you get the foundations of the hospital going with the ED doc group, start expanding by inviting the other independent physicians to join up and have nuances that say even in the outpatient the must also be 100% Physician.
5) Play hardball with the insurance companies - not physician/patient friendly, don't sign the contracts, and advertise with big huge signs out front that say "we are NOT contracted with these insurance companies due to not meeting physician nor patient friendly standards, we are a vector for change and change can be rough... etc etc"
6) consider no medicaid and no medicare too, but be willing to offer prorated care for government insurance patients
7) ED should actually do MSE and discharge if not appropriate for ED visit - reclaim the ED

I've thought about trying to kick start a Physician only medical group that slowly expands as a multispecialty on the outpatient side of things, that doesn't do government insurance, nor low paying bad actor insurance companies, and advertises aggressively how it is 100% physician only.
 
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DragonSalad

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"Section 8 — President-Elect: Any member of the Board of Directors excluding the president, president-elect, and immediate past president shall be eligible for election to the position of president-elect by the Council. The president-elect shall be a member of the Board of Directors. The president-elect's term of office shall begin at the conclusion of the meeting at which the election as president-elect occurs and shall end with succession to the office of president. The president-elect shall be elected by a majority vote of the councilors present and voting at the annual meeting of the Council."

So how do you change ACEP with this democratic structure currently in place?
 

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Reform also needs pushing out some of the bad insurance companies.

It pains me to rip on some of the for profit insurance companies, but some have gone too far. A physician push to establish and open non-profit physician run health insurance companies could be another angle for change.

I know PacificSource is one Non-profit insurance company on the West Coast, but not sure if there are others in the country.
 
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Physicians as a whole need to be willing to stop working. The only negotiating tactic that matters is willingness and ability to walk.

Imagine a world where all EM physicians woke up one day and said "fuq this, I'm not going to work again until pay is x, and working conditions are y." The hospitals would shyt their pants and would cave immediately. The problem is, there are always a handful of rats who will keep working for pennies (Denver is down to $125/hr with U-SUCK lmao) and in dangerous working conditions out of some perverse "morality" or actual immediate financial need.

Physicians are notoriously awful with personal finance so this dream of mine will never happen. I could stop working today and be totally fine for a year or longer (and I have a kid). If only my colleagues realized they shouldn't:

-Have a 1 million dollar home which they pay 30k/yr in taxes on
-Send their kids to private school, when they are already paying a stupid amount of income/property tax
-Pay for their kids to have horses
-Have a new 50k+ car every 5 yrs
-Spend 30k on vacations every year

They could be financially free of the corporate world we live in.

100%

A physician strike would bring the US healthcare system to its knees. Who would they bring in as scabs - NPs? Lol
 

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An interesting article on the many obstacles that we face in any pursuit of forming a union for collective bargaining.


The reality is that SDGs will never take over CMGs. It's naive and wishful thinking. The CMG can run the business better, with greater efficiency, possess more leverage, more liquid assets, greater negotiating power, and houses a team of lawyers and executives whose sole job is to analyze and optimize the business operations for maximum efficiency. (While milking the MDs for every extra penny, I'll admit.) Most doctors aren't MBAs and have no salient interests in running a business whatsoever. If you took a poll of most EPs...most of us want to clock in and clock out with zero responsibilities outside of work. It's sad but 100% true.

Our greatest negotiating power was our scarcity. Think about that. Our scarcity.... After all, it has enabled us to traditionally demand large salaries, large sign ons, and many other concessions gleaned from the CMGs over the years while they still remained profitable. Well, of course they support and drive the oversupply of EPs on the market with CMG sponsored residency programs. It takes away the only negotiating chip we had at our disposal. Too many new academic EP lambs to the slaughter who's only concern is "teaching" residents and being involved in "academics" with these ridiculous ideological and utopian coke bottle glasses who are slowly but surely helping spread the cancer among our ranks. Want to do some good? It's not wasting energy trying to form an SDG in a city where you're up against TH and the rest of the big boys where they have an army against your 5 man group. It's refusing to be an academic physician for a CMG sponsored new residency at some of these disgraceful community sites.
 
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Birdstrike

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A thought experiment, if you will... Just play along.

We all know things aren't headed in the right direction. This forum is full of great threads on topics related to midlevel expansion, the nefarious practices of CMGs, and the glut of garbage residency programs popping up everywhere.

I am guilty of this more than anyone, namely, complaining. That's not what this thread is about.

While many of the apathetic EM souls will say, "we are too far gone, the last shoe has already dropped", I would argue that the next 10 years are going to be critical to "save" our specialty, so to speak. I believe it can be done.

I recognize this is David vs. Goliath. I recognize the American health care system, the CMGs, insurance companies, are all working against us. But collectively, as a group of physicians, I believe we can steer our specialty away from from the inevitable iceberg.

Propose solutions, that we as individual physicians, can partake in. "Go into pain" or "Switch specialities" is not a solution. Perhaps a grassroots approach will work better.

Watch for inspiration:
I feel ya, man. This post could have been written by me, 10 years ago. But I've learned a few things in the last decade. I've learned a lot about the difference between burnout vs feeling energized, inertia vs action, following vs leading, and complaining vs solutions.

It sounds like your goal is group solution, such as meaningful change for the entire specialty of Emergency Medicine. Short of an Emergency Physician strike which would mean people dying in empty EDs while thousands of good-guy/good-gal physicians stick to their guns and say, "Gimme us money, oppress nurse practitioners and abandon 'patient satisfaction' or the dying continues," nothing is likely to ever change.

That leaves you with individual solutions, taking your own lead, putting your own plan into action so you can feel energized. Otherwise you're beholden to the complaining and inertia of the leaderless masses, while you wait for a "revolution" that's never going to happen.

Your fellow rule-following physicians are not likely to do anything sufficiently aggressive or rebellious to "fight the power," or risk their paycheck to meaningful change. Maybe this time is different, I don't know. I suppose I could be wrong. But for twenty years I've been listening to this same talk and no one has done anything but complain, while letting the powers that be have their way, in exchange for being able to maintain their doctor lifestyle with a steady paycheck.

The solution is to make your own solution. Make yours now.
 
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TheComebacKid

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Some great suggestions on here...

Regarding the idea of physician-run hospital systems... Physicians are notoriously terrible at the majority of business/administrative tasks that are required to efficiently run any business entity. When you drop greater than 200K into the arduous task of just learning medicine, learning accounting, taxes, marketing etc is not very appealing. That being said, I don't think we can effectively regain control over things without a greater role in these arenas.

We need to work our way up the organizational structure of the hospitals to exert more influence. If you want the chops to do it, an MBA may be helpful, but I recognize that not everyone will want to go through the extra training. That being said, you can still find ways to be involved. Sitting on hospital committees, obtaining more transparency regarding billing, etc.

It pains me to say this, but I think over the next decade, the simple set up in EM where you punch in, see your patients, punch out, needs to change. I recognize that the on/off nature of our specialty is what makes it so appealing to many. But in order to make the specialty palatable and worthwhile for the next generation of EM docs (and even those who are currently in training at this point), we have to be willing to get involved, in some capacity, even if we didn't sign up for it.
 
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SDGs need help competing with CMGs. They need to be able to subcontract out their billing, recruitment, scheduling, legal, management, etc, etc, etc without getting hosed by those companies.

AAEM has something to help with this - Home | AAEM Physician Group

I have no idea if its actually useful.
 

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Which has the greatest likelihood of success,

A) Changing your own personal situation, or

B) Changing an entire medical specialty and interconnected industries?
 
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sloh

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What's more likely,

A) Changing your own personal situation, or

B) Changing an entire medical specialty and interconnected industries?

The biggest obstacle to B is the Nash Equilibrium.

If each player has chosen a strategy—an action plan choosing its own action based on what it has seen happen so far in the game—and no player can increase its own expected payoff by changing its strategy while the other players keep theirs unchanged, then the current set of strategy choices constitutes a Nash equilibrium.
 
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Birdstrike

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The biggest obstacle to B is the Nash Equilibrium.

If each player has chosen a strategy—an action plan choosing its own action based on what it has seen happen so far in the game—and no player can increase its own expected payoff by changing its strategy while the other players keep theirs unchanged, then the current set of strategy choices constitutes a Nash equilibrium.
That's right. There's no durable incentive for any of the parties to change course. Therefore, nothing changes. A few individuals in one group (EM physicians) may want to change strategies (for improved work conditions) by changing the incentives of the other groups (CMGs, Hospitals, Government) and forcing a change in strategy (by going on strike, for example). But they cannot do so if the majority cannot change strategy (due to living paycheck to paycheck) or lack the desire because of prioritizing maintenance of lifestyle.

It's the perfect conditions for equilibrium, guaranteeing a lack of change. Only by removing the other parties, and pursuing individual solutions, can meaningful change occur.
 
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EctopicFetus

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An interesting article on the many obstacles that we face in any pursuit of forming a union for collective bargaining.


The reality is that SDGs will never take over CMGs. It's naive and wishful thinking. The CMG can run the business better, with greater efficiency, possess more leverage, more liquid assets, greater negotiating power, and houses a team of lawyers and executives whose sole job is to analyze and optimize the business operations for maximum efficiency. (While milking the MDs for every extra penny, I'll admit.) Most doctors aren't MBAs and have no salient interests in running a business whatsoever. If you took a poll of most EPs...most of us want to clock in and clock out with zero responsibilities outside of work. It's sad but 100% true.

Our greatest negotiating power was our scarcity. Think about that. Our scarcity.... After all, it has enabled us to traditionally demand large salaries, large sign ons, and many other concessions gleaned from the CMGs over the years while they still remained profitable. Well, of course they support and drive the oversupply of EPs on the market with CMG sponsored residency programs. It takes away the only negotiating chip we had at our disposal. Too many new academic EP lambs to the slaughter who's only concern is "teaching" residents and being involved in "academics" with these ridiculous ideological and utopian coke bottle glasses who are slowly but surely helping spread the cancer among our ranks. Want to do some good? It's not wasting energy trying to form an SDG in a city where you're up against TH and the rest of the big boys where they have an army against your 5 man group. It's refusing to be an academic physician for a CMG sponsored new residency at some of these disgraceful community sites.
I disagree. We all need a job. Just this week a 40 doc SDG took over a team health contract in Kansas City. It’s doable and it’s the only way. To get 30k+ docs to not take a job when CMGs make up 50+% of the jobs is never gonna happen. Can a group of docs win a contract yes. I also think you overestimate the intellect and skill of the CMGs. These aren’t Harvard biz grads. It’s like the cno of your hospital. A bsn From a no name university and an mba from some bs online/ night school program.
 
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Arcan57

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I disagree. We all need a job. Just this week a 40 doc SDG took over a team health contract in Kansas City. It’s doable and it’s the only way. To get 30k+ docs to not take a job when CMGs make up 50+% of the jobs is never gonna happen. Can a group of docs win a contract yes. I also think you overestimate the intellect and skill of the CMGs. These aren’t Harvard biz grads. It’s like the cno of your hospital. A bsn From a no name university and an mba from some bs online/ night school program.
What the CNO doesn't have is f%#$ tons of venture capital. That's the beauty of unbridled capitalism. The idiots don't have to outthink you, they just have to outspend you long enough that you're no longer a going concern. The CMG doesn't even have to keep the contract, every time they buy out or kick out an independent group, the fallout from that process typically finishes off the group. The people that had the skills and will to keep a contract get bought off, and everyone else sees their conditions worsen and blame both the CMG and the fat cat old leadership.
 
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What the CNO doesn't have is f%#$ tons of venture capital. That's the beauty of unbridled capitalism. The idiots don't have to outthink you, they just have to outspend you long enough that you're no longer a going concern. The CMG doesn't even have to keep the contract, every time they buy out or kick out an independent group, the fallout from that process typically finishes off the group. The people that had the skills and will to keep a contract get bought off, and everyone else sees their conditions worsen and blame both the CMG and the fat cat old leadership.

Add on top of that the fact that they don't care about the unimportant things... you know, like... good medicine... physician morale... etc.
 
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I imagine this will become a cyclical thing: SDGs -> CMGs -> employees -> SDGs and so on
I think hospitals realized that the short term money they can save by bringing in a CMG to gut their ER has made their satisfaction scores go down and employees very unhappy. I'm seeing a lot of hospitals boot the CMGs and form into large groups and adopt employee model staffing.
 
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Groove

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I disagree. We all need a job. Just this week a 40 doc SDG took over a team health contract in Kansas City. It’s doable and it’s the only way. To get 30k+ docs to not take a job when CMGs make up 50+% of the jobs is never gonna happen. Can a group of docs win a contract yes. I also think you overestimate the intellect and skill of the CMGs. These aren’t Harvard biz grads. It’s like the cno of your hospital. A bsn From a no name university and an mba from some bs online/ night school program.

@Arcan57 beat me to it. I partially agree with you but these guys have one thing that most of us don't have and it makes ALL the difference.



They can better sustain strategic delayed revenue streams and forego things like hospital subsidies in a market with a poor payer mix, etc.. All the dirty tricks that a small SDG with money pooled from the docs and a single business loan can't pull off easily. Plus, the irony is that most of these CMGs started out as private groups. I know a private group about 1.5 hours South of me that has now branched out into several ED's and is doing locums, Telehealth and consulting on top of their current contracts. The last time I read up on them it was sounding more and more like APP when they were small.
 
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Arcan57

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I imagine this will become a cyclical thing: SDGs -> CMGs -> employees -> SDGs and so on
I think hospitals realized that the short term money they can save by bringing in a CMG to gut their ER has made their satisfaction scores go down and employees very unhappy. I'm seeing a lot of hospitals boot the CMGs and form into large groups and adopt employee model staffing.
Hospitals dislike CMGs for a variety of reasons. The biggest being that the government has decided that the hospital is the unit of control for inpatient healthcare outcomes and expenses. Since most modern hospitals have the majority of their patients start off in the ED, not having direct control over the ED docs is perceived as risky. CMG are tolerated because most hospital chains don't have the resources to recruit. Recruiting in undersaturated markets while your hospital chain is growing requires a regional or nationwide network. That network is stupidly expensive to set up, and relatively expensive to maintain and hospitals usually only need an effective recruiting network for a handful of years until they're full and their populations stabilize. Once ED doc levels reach a steady state, the hospital starts thinking heavily about why they're letting revenue go out the door to someone else's shareholders.; They also start fantasizing that all those pesky adverse to quality events coming from the ED would go away if the ED docs were under their control. Team getting kicked out of Houston would be a great example of this process.

Incidentally, trying to avoid getting bumped out after they've done the recruiting is the origin of the proliferation of non-compete clauses that forbid you from working at the hospital currently employing you. It's got nothing to do with keeping you from leaving and everything to do with keeping the hospital from terminating the CMG and just rehiring you without the middleman.
 
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EctopicFetus

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Some
Some places still interpret employed ED providers as violating the Frank-Stark law (anti-kickback law) by "self-referring" admissions.
Some states have laws whereby hospitals cant employ hospital based docs like Rads, EM, Anesthesia.

Regarding the SDG vs CMG thing.. all you guys make solid points. You are also living in a "subsidized" world. That world is quickly leaving though if we get major cuts it may return.

Why cant an SDG be run more efficiently than a CMG. If it can then surely they need a smaller subsidy given lower overhead. Insurance is another MAJOR factor. The insurance companies are sick and tired of dealing with the CMGs. SDGs can get solid rates but there has to be room to go out of network.

Like I pointed out some SDGs are taking contracts from the CMGs. I know of a few SDGs forming from "thin air" with no tie to another group. While I will maintain until I am blue in the face SDGs will, can and should outearn CMGs even if the pay was equal the control is worth it. Pay a few of your docs to do admin work. everyone else can punch in and out. Most SDGs I know are making $300+/hr. That is long gone in the CMG world and with the issues discussed before (MLP proliferation and residencies popping up faster than weeds) those days are gone. An SDG is fairly immune to these forces.
 
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Alvarez13

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Regarding striking as an emergency physician, its unethical to let the patient suffer. What we do is collectively agree to not sign any of our notes for a week. Continue to see pts. Notes can be seen by consultants and other EM docs. They can't be collected on if we don't sign. Think of the enormous losses for hospital employees and CMGs. Statement made.
 
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As the number of residency graduates expands why are we not pushing for only BC/BE docs staffing EDs.
 
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Backpack234

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I would love to see ACEP take a stand vs CMGs. Write letters to hospital CEOs telling them the perverse nature of PE backed companies. Floating the benefits of SDGs and gasp organizing local docs to kick out the CMGs and take over as SDGs. AAEM can do this too.

It can only be won an inch at a time. News today that envision lost a few contracts to some SDG in KC. Wins are popping up slowly but surely.

We have to be willing to organize locally and this is the hard part.

what news?
 

Birdstrike

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Regarding striking as an emergency physician, its unethical to let the patient suffer. What we do is collectively agree to not sign any of our notes for a week. Continue to see pts. Notes can be seen by consultants and other EM docs. They can't be collected on if we don't sign. Think of the enormous losses for hospital employees and CMGs. Statement made.
That'll show 'em.
 
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Regarding striking as an emergency physician, its unethical to let the patient suffer. What we do is collectively agree to not sign any of our notes for a week. Continue to see pts. Notes can be seen by consultants and other EM docs. They can't be collected on if we don't sign. Think of the enormous losses for hospital employees and CMGs. Statement made.

I've always heard people talk about this documentation strike approach, and while it sounds good in theory, it fails the "is it actually feasible" test.

There's absolutely NO WAY that EM physicians would be able to coordinate that sort of thing. We can't even coordinate ourselves as a specialty to address the existing issues, god forbid we'll be able to collectively act when it comes to our EMR.

Within 24 hours a vast majority of EM docs worried about their job security would falter and end up completing their notes. This wouldn't last a single day in my opinion.

But yes it's a nice wet dream!
 
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Birdstrike

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I've always heard people talk about this documentation strike approach, and while it sounds good in theory, it fails the "is it actually feasible" test.
It's also just about the weakest opening play you could ever make in a negotiation. "Give us what we want! Or....or...or...We won't do paperwork!" It's like going to battle wearing pink, whining, armed with a straw and some spit wads, when you need to be in full military gear, driving a tank and ready to win if it means you lose everything in the process. It shows a complete lack of understanding of negotiations, which is something healthcare CEOs are experts at. Hospital administrators would chew this up and spit it out in 5 minutes, declare victory and walk away with a laugh.

The fact that such a thing has even been considered, proves what I said above:

Your fellow rule-following physicians are not likely to do anything sufficiently aggressive or rebellious to "fight the power," or risk their paycheck to meaningful change.
Until you're sufficiently ready to overturn a system by acting in a way that's sufficiently aggressive and rebellious, and will require tremendous sacrifice, you might as well find a way to make the current system work for you.
 
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Brigade4Radiant

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Regarding striking as an emergency physician, its unethical to let the patient suffer. What we do is collectively agree to not sign any of our notes for a week. Continue to see pts. Notes can be seen by consultants and other EM docs. They can't be collected on if we don't sign. Think of the enormous losses for hospital employees and CMGs. Statement made.

Nope all you need is a medical director and MPM PA and have them just signed the charts under the medical director. Also while you’re Working you also take liability so not documenting just leaves you to face even more liability in case of a lawsuit.

Also it’s hard to see how effective the strike would be because you don’t know if the other doctors are actually signing their charts. Also corporate medical groups can last longer than your typical ED.

It’s a big deal when a paycheck is one day late you’re asking people to deal with all the stress of the ED without getting paid and the liability seriously think about this it’s laughable
 
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bravotwozero

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Realistically you're only option is your ability to walk away from a Job. You can capitalize on this by:

#1) Suck it up butter cup, use earnings to sock away enough money to meet your passive income goals, then tell everybody off at your job that you don't like and walk away for good.

#2) Move to a state that allows you to open your own FSED, or join an existing one.

#3) Open your own Urgent Care.

#4) Take a pay cut and go into either academics, military, or the VA.

#5) Go overseas, to a place like dubai, where you don't pay a dime in income tax to the local government, and have a significantly reduced one to Uncle Sam as well.

#6) Do a fellowship and exit the specialty entirely.
 
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EctopicFetus

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Realistically you're only option is your ability to walk away from a Job. You can capitalize on this by:

#1) Suck it up butter cup, use earnings to sock away enough money to meet your passive income goals, then tell everybody off at your job that you don't like and walk away for good.

#2) Move to a state that allows you to open your own FSED, or join an existing one.

#3) Open your own Urgent Care.

#4) Take a pay cut and go into either academics, military, or the VA.

#5) Go overseas, to a place like dubai, where you don't pay a dime in income tax to the local government, and have a significantly reduced one to Uncle Sam as well.

#6) Do a fellowship and exit the specialty entirely.
#3 is one option but a better solution is passive income/business unrelated to EM. If you did well enough in real estate it could make you more than enough. It isnt easy but there are some people who have figured it out. I’m not one of those people but I know some folks.
 

bravotwozero

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I've thought about real estate investing many times, but each time I couldn't answer the question 'why the heck would I go through the hassle of real estate investing if can just park the money in an index fund?'
 
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I've thought about real estate investing many times, but each time I couldn't answer the question 'why the heck would I go through the hassle of real estate investing if can just park the money in an index fund?'

Because this hope of index funds returning 9% (or whatever the number du jour is) is exactly that... a hope. Past performance doesn't guarantee any future returns and a variety of market experts have been talking about an upcoming dead decade. Who knows if this bogleheads / MMM / Ride the indices approach will actually be feasible over the next 20-30 years.
 

bravotwozero

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Past performance doesn't guarantee future returns, but can be a pretty good indicator. The stock market did go through a couple of world wars, a prior pandemic, the great depression, an oil embargo, and hyperinflation before. And It's not like I'm retiring tomorrow. If there's going to be a 'dead decade' or whatever, landlords will get hit just as hard as tenants will have problems paying rent, and businesses can go belly up and not pay their commercial property leases.
 
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sloh

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Past performance doesn't guarantee future returns, but can be a pretty good indicator. The stock market did go through a couple of world wars, a prior pandemic, the great depression, an oil embargo, and hyperinflation before. And It's not like I'm retiring tomorrow. If there's going to be a 'dead decade' or whatever, landlords will get hit just as hard as tenants will have problems paying rent, and businesses can go belly up and not pay their commercial property leases.

To piggyback off this:

Adam Fayed's answer to Why do so many people still believe real estate investing is a better investment than stocks when data does not support that argument? - Quora

"There are also many expressions which are simply not true, like “you can’t lose with property”, renting is dead money etc. Seldom do the media actually compare the returns of property and stocks. They also don’t report on long-term trends. I will give you a great example. If you asked the average person in the UK “have UK house prices gone up in real terms in the last 13 years” they would say yes, but that is factually incorrect. UK house prices have indeed hit nominal records, but not inflation adjusted records.

Most people ask “do you want to invest in property”. Few people ask “do you want to start your own business in property”. But in reality owning properties is essentially running your own business. Many tax authorities globally, including HMRC in the UK, consider it as such. The reason is simple. You have cashflow management to consider - in other words money coming in and out. You have time pressures unless you outsource it to a property management company. You also need to consider how to use leverage/debt well. So it is much more complex and time consuming than a passive investment like a REITs, ETF or index fund. For that reason, I have seldom seem amateur landlords do well long-term vs the markets, unless they get in at the right time, or have done a lot of research. I have seen some professionals do it, in the same way I have seen countless people do very well in other business areas.

The media doesn’t make any distinction between holding individual stocks vs the whole market (index funds), in the same way they seem to make no distinction between being long-term and short-term.

So they seldom mention facts like nobody has been down over a 25 year period if they just bought and held the S&P500 index.

In comparison, with property developments, and even “ready made real estate”, you can lose 100% of your money, which can never happen with a collective investment like the S&P500."
 
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Hamhock

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I've thought about real estate investing many times, but each time I couldn't answer the question 'why the heck would I go through the hassle of real estate investing if can just park the money in an index fund?'

Diversification.

HH
 
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Old_Mil

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A thought experiment, if you will... Just play along.

We all know things aren't headed in the right direction. This forum is full of great threads on topics related to midlevel expansion, the nefarious practices of CMGs, and the glut of garbage residency programs popping up everywhere.

I am guilty of this more than anyone, namely, complaining. That's not what this thread is about.

While many of the apathetic EM souls will say, "we are too far gone, the last shoe has already dropped", I would argue that the next 10 years are going to be critical to "save" our specialty, so to speak. I believe it can be done.

I recognize this is David vs. Goliath. I recognize the American health care system, the CMGs, insurance companies, are all working against us. But collectively, as a group of physicians, I believe we can steer our specialty away from from the inevitable iceberg.

Propose solutions, that we as individual physicians, can partake in. "Go into pain" or "Switch specialities" is not a solution. Perhaps a grassroots approach will work better.

Watch for inspiration:

It's already hit the iceberg. It's taking on water now. This is the bottom line: corporate medicine has determined that a large number of ED patients can be seen more cheaply by PAs and NPs at the exact same time that there is an oversupply of new EM graduates thanks to too many residency programs opening.
 
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Bougiebuster

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A thought experiment, if you will... Just play along.

We all know things aren't headed in the right direction. This forum is full of great threads on topics related to midlevel expansion, the nefarious practices of CMGs, and the glut of garbage residency programs popping up everywhere.

I am guilty of this more than anyone, namely, complaining. That's not what this thread is about.

While many of the apathetic EM souls will say, "we are too far gone, the last shoe has already dropped", I would argue that the next 10 years are going to be critical to "save" our specialty, so to speak. I believe it can be done.

I recognize this is David vs. Goliath. I recognize the American health care system, the CMGs, insurance companies, are all working against us. But collectively, as a group of physicians, I believe we can steer our specialty away from from the inevitable iceberg.

Propose solutions, that we as individual physicians, can partake in. "Go into pain" or "Switch specialities" is not a solution. Perhaps a grassroots approach will work better.

Watch for inspiration:

Where are we with this? Anyone spearheading any change? Unionizing? Bueller?...
 

thegenius

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It's already hit the iceberg. It's taking on water now. This is the bottom line: corporate medicine has determined that a large number of ED patients can be seen more cheaply by PAs and NPs at the exact same time that there is an oversupply of new EM graduates thanks to too many residency programs opening.

As much as I hate this....I think you are right. probably 1/3 to 1/2 of the patients that show up to the ED don't even need to be there, and it doesn't matter what you do (just discharge, order labs and discharge, xray and discharge, abx or no abx, etc.). It's sad. '

If you were an insurer and knew this, would you want to pay premium charges?
 
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BAM!

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It's already hit the iceberg. It's taking on water now. This is the bottom line: corporate medicine has determined that a large number of ED patients can be seen more cheaply by PAs and NPs at the exact same time that there is an oversupply of new EM graduates thanks to too many residency programs opening.
The line they feed at the CMG meetings to justify midlevels in the ED is that their existence increases reimbursement of the CMG doctors. Lower reimbursement rate trends lead to lower hourly rates. To compensate for this, hire mid levels to see more patients but pay them less than what they bill. Otherwise, if you only had MDs, all the MDs in the group would be paid less. This is the CMG rationale.
 
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