Visit Volume vs Pay

[Old_Mil]

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All other things being equal, do you all think that a IC job at a 6500 visit a year facility that pays 90/hr+malpractice+tail is superior to an IC job at a 2500 visit a year facility that pays 65/hr+malpractice-tail?

The extra money is always nice, I'm just weighing the additional work and malpractice risk generated by going to the busier place vs the cash.

How much does tail coverage cost out of pocket should it become necessary?

 

[southerndoc]

All other things being equal, do you all think that a IC job at a 6500 visit a year facility that pays 90/hr+malpractice+tail is superior to an IC job at a 2500 visit a year facility that pays 65/hr+malpractice-tail?

The extra money is always nice, I'm just weighing the additional work and malpractice risk generated by going to the busier place vs the cash.

How much does tail coverage cost out of pocket should it become necessary?

Tail coverage can range from $30k-100k depending on number of patients seen, how many years you've been practicing, any suits brought against you already, state law (i.e., statute of limitations for ability to sue), etc.

 

[Arcan57]

I'd go with the busier place because of the more pay and paid tail, as well as the fact that it's busier. At 6500 visits, assuming single coverage, that's still only 17 visits per day. I'm guessing these are 24 hour shifts?

 

[Old_Mil]

I'd go with the busier place because of the more pay and paid tail, as well as the fact that it's busier. At 6500 visits, assuming single coverage, that's still only 17 visits per day. I'm guessing these are 24 hour shifts?

Yep.

Sounds like buying a tail can be an expensive proposition.

Why would "busier" be a selling point? That's just more potential drug seekers, acute exacerbations of fibromyalgia, crippling neurologic injuries following 10mph MVCs, and lawsuits walking through the door.

(No, I'm not cynical)

 

[deleted109597]

They couldn't get me to do $90 an hour if it was watching television. I can't fathom $65 an hour.

 

[Antibodies]

Help a med student out... isn't $90 an hour pretty low?

 

[Old_Mil]

Help a med student out... isn't $90 an hour pretty low?

Not really, not for this size of department.

The real question: ...is seeing an extra 4,000 patients a year (and the work/malpractice risk that entails) worth an extra $25 an hour + tail.

 

[The White Coat Investor]

$90/hour is pretty low. I wouldn't take a job less than $150/hour unless it was rapidly leading to parternship. And even then I wouldn't go less than $100/hour. $70? P.A.s can make $70.

A tail costs ~$22K after one year, $44K after two, and $55K when "mature" (~5 years.)

 

[Arcan57]

Yep.

Sounds like buying a tail can be an expensive proposition.

Why would "busier" be a selling point? That's just more potential drug seekers, acute exacerbations of fibromyalgia, crippling neurologic injuries following 10mph MVCs, and lawsuits walking through the door.

(No, I'm not cynical)

We have a productivity bonus that's RVU based, but mostly I can't stand just sitting around during a shift. I don't (and never will) do 24hr shifts, but I can understand that less busy usually translates into more hours spent sleeping. On a side note, there is no way in hell I would expose myself to any medicolegal risk for $65/hr. Even if you were working 10 24's per month (240 hrs/month), that's still only $180k/yr.

 

[alreadylernd]

I interpretted the 90/hr and IC (independent contractor) as the rate is 90/hr plus whatever the MD bills for as an IC? Which would make the salary higher, though perhaps not much if it's only about 17 patients/day.

6500 yr still isn't too busy, which certainly would affect billing ability - probably lots of level 3-4s, few procedures, which is why they have to offer you some kind of floor-rate. But I wouldn't expect the difference in volume to influence the malpractice risk as both hospitals are probably sleepy little places.

 

[Old_Mil]

There is no RVU in this. Its straight pay.

Both hospitals are sleepy little places, but 6500 patients a year is 17 patients a day, while 2500 patients a year is 7 patients a day.

Figuring 10 shifts, the $65 a year shop would result in $187,200 gross (roughly $118,800 net a year), the $90 a year shop would result in $259,200 (roughly $157,700 net a year).

So is an extra $40k a year worth doubling the malpractice risk...Also, 7 patients a day makes it more likely to be able to get a good night's sleep making it more likely that you could string together multiple 24 hour shifts - and the slower hospital lets you take home call for the ED so I suspect I could spend most of those nights sleeping soundly at home in my bed and getting paid for it.

(For those of you wondering if I'm nuts, it's all about lifestyle at this point. Nothing about my wants or needs is going to be affected by making an extra $40k a year. I can essentially support the lifestyle I'd want on around $60k a year, and everything over that goes into the bank or towards zeroing the balance on student loans).

 

[deleted109597]

If it is worth it to you, then go for it.
It isn't worth it to me personally.

As far as malpractice risk, while you might double it, it still wouldn't be inordinately high. Barring complete incompetence/lack of bedside manner, you aren't seeing enough at either to get sued on a regular basis.

Family?

 

[Old_Mil]

As far as malpractice risk, while you might double it, it still wouldn't be inordinately high. Barring complete incompetence/lack of bedside manner, you aren't seeing enough at either to get sued on a regular basis.

Family's good with any of the options; thanks for this...

(Given the complete asshats I've seen during training not only is being sued on a regular basis a concern, getting mugged on the way to the car is a concern, getting carjacked on the way home is a concern...i've sort of come to the conclusion that ensuring happiness in medicine is a matter of minimzing one's exposure to actual patients...)

 

[The White Coat Investor]

Figuring 10 shifts, the $65 a year shop would result in $187,200 gross (roughly $118,800 net a year), the $90 a year shop would result in $259,200 (roughly $157,700 net a year).

(For those of you wondering if I'm nuts, it's all about lifestyle at this point. Nothing about my wants or needs is going to be affected by making an extra $40k a year. I can essentially support the lifestyle I'd want on around $60k a year, and everything over that goes into the bank or towards zeroing the balance on student loans).

Why are you working so many hours then?

$187,200/$65=240 hours a month. That's hardly a nice lifestyle. I work half that (for ~ same pay, and I haven't made partner yet.) Some people in my group work 50 hours a month. Now that's a lifestyle.

 

[gro2001]

I am only a med student, but it seems a little bit strange (even in a handy-wavy gross approximation way) to say that malpractice risk is doubled just because your volume is doubled. You could go to a lower volume place, have the false sense of security while the bigger place may have better systems to catch errors, more staff who may bring things to your attention you might miss, different patient population that is just less likely to sue, more specialists available (some people think that getting lots of consults may decrease liability). I don't know where that is actually the case at the two institutions you are thinking about, or whether any of these has as significant an impact on malpractice rates as pure volume, but I think they cloud the estimate to a sufficient degree (especially since you are asking whether the extra income is worth doubling the malpractice risk) to make the assumption of '2x volume = 2x malpractice risk' invalid.

 

[Old_Mil]

I am only a med student, but it seems a little bit strange (even in a handy-wavy gross approximation way) to say that malpractice risk is doubled just because your volume is doubled. You could go to a lower volume place, have the false sense of security while the bigger place may have better systems to catch errors, more staff who may bring things to your attention you might miss, different patient population that is just less likely to sue, more specialists available (some people think that getting lots of consults may decrease liability).

This is only true if you actually believe that there is some actual malpractice behind malpractice suits. When I was in medical school, our school arranged (paid) a plaintiffs' attorney to come speak to us. At the start of his lecture on med-mal he asked the assembled throng what they thought the key to a successful suit was. A number of answers were thrown out from substandard care to bedside manner but his response was "the plaintiff." He said that "regardless of what the facts of the case were, what the patient had, or what the outcome was" he wouldn't take the case on if it was the wrong plaintiff (ie, one who could not make the necessary emotional connection to the jury and thereby get the right verdict).

I'm not sure what the actual relationship is between volume, acuity, and lawsuits - whether it is linear or not -but it would seem logical that more encounters = more exposure...and that working in a tertiary care setting where you're getting your ass kicked by seeing 2-3 high acuity patients an hour would maximize that risk even if you cut down on your number of shifts to minimize hours at work.

It would seem to me as if minimizing discrete patient encounters would be a better strategy than minimizing hours at work insofar as you can't get sued for down time. If you can get paid for that downtime during which you're not exposing yourself to getting sued so much the better.

 

[alreadylernd]

I am only a med student, but it seems a little bit strange (even in a handy-wavy gross approximation way) to say that malpractice risk is doubled just because your volume is doubled. You could go to a lower volume place, have the false sense of security while the bigger place may have better systems to catch errors, more staff who may bring things to your attention you might miss, different patient population that is just less likely to sue, more specialists available (some people think that getting lots of consults may decrease liability). I don't know where that is actually the case at the two institutions you are thinking about, or whether any of these has as significant an impact on malpractice rates as pure volume, but I think they cloud the estimate to a sufficient degree (especially since you are asking whether the extra income is worth doubling the malpractice risk) to make the assumption of '2x volume = 2x malpractice risk' invalid.

Hit the nail right on the head. One thing to look into at both of these places is who admits patients/how are they admitted. At tiny hole-in-the-walls, you really don't want to get caught writing "holding" orders or having patients board in your ER "overnight" to be admitted in the morning. That would open you up to an entirely different kind of risk. Look too at what your floor responsibilities are, because again, you may be the only doc in the hospital and may be called to the floor to assess a decompensating patient...

 

[gro2001]

his response was "the plaintiff."

I see your point. Perhaps the strongest factor among all of these is the nature of the patient (both personal and cultural). In fact, that would be my guess as well. But I would argue that this does not translate into a straight forward "if I go to an institution where I will have fewer encounters I have a lower risk of suits". All else being equal, sure. But all else is rarely equal. Once again, maybe the two hospitals you are talking about are almost identical on aspects other than the volume and are actually across the street from each other and draw from exactly the same pool of patients. But odds are, one is either more rural, or less insured mix, or more immigrants, or has a better name in the community, or has a ambulance chaser office across the street, or a million other patient-centered factors other than volume.

 

[KYTNOH]

If lifestyle is the major driving factor, I don't think I would work 10, 24 hour shifts a month. I think I would go with a place that saw 1.5-2.0 patients per hour and make $140-180/hr in addition to benefits. That way you could work fewer hours. There are plenty of these opportunities out there. Ten 10 hour shifts at 150 bucks an hour will gross you $180,000 a year. You would be working less than half the hours but essentially the same pay.

The other consideration would be to get a higher hourly pay for those low volume places. If they are really starving for physician coverage then you could demand more money to work there. You may be able to get them to supplement you income since they have to staff it with someone.

 

[EM_Rebuilder]

There is no RVU in this. Its straight pay.

Both hospitals are sleepy little places, but 6500 patients a year is 17 patients a day, while 2500 patients a year is 7 patients a day.

Figuring 10 shifts, the $65 a year shop would result in $187,200 gross (roughly $118,800 net a year), the $90 a year shop would result in $259,200 (roughly $157,700 net a year).

So is an extra $40k a year worth doubling the malpractice risk...Also, 7 patients a day makes it more likely to be able to get a good night's sleep making it more likely that you could string together multiple 24 hour shifts - and the slower hospital lets you take home call for the ED so I suspect I could spend most of those nights sleeping soundly at home in my bed and getting paid for it.

(For those of you wondering if I'm nuts, it's all about lifestyle at this point. Nothing about my wants or needs is going to be affected by making an extra $40k a year. I can essentially support the lifestyle I'd want on around $60k a year, and everything over that goes into the bank or towards zeroing the balance on student loans).

I am glad to see someone that is EM trained filling the void in Rural Emergency Medicine. Thats where we are going to run into a 'problem' in our speciality. AAEM thinks ONLY BC/BE EM should work in every single ED in the country... People like myself, and probably 99% of the other folks on this board, would cringe at the thought of working full time at a shop like being described here. For most of us, that was maybe the first few shifts we moonlit at then moved on to bigger places... I guess I am spoiled, but I wont hardly leave the house for less than 200/hr and I am still a resident. The best gigs are when the place you are describing NEEDS a doctor and pays double pay. There is just a good feeling about sleep and making 200/hr..

I am glad to see you are going to take high quality emergency care to some rural folks; take whichever job you are more comfortable with. I would still try to work an occasional shift at a nearby ED as PRN just to keep your skills up...

 

[Old_Mil]

In the end I decided to go with the lower volume, lower pay shop. There are a lot of different ways to slice it, I suppose but 40,000 of post tax income divided over a 4,000 increase in patient volume essentially works out to $10 a head in your pocket for the extra work you'd be doing. While 6,500 would be no problem volume wise single coverage, it's probably just busy enough to interrupt sleep on a regular basis. At the slower shop I can work two blocks of five 24 hour shifts in a row and have 20-21 days off in every month not named February. I'll probably get paid for sleeping a good number of the days I am at work...and if I pick up shifts at the other rural hospital a half hour down the road with half the volume of this one, I can even get paid for sleeping at home. I'm not lazy-just tired-and really looking forward to the end of residency. Oh, and I can buy a nice house for around $100k.

 

[Mighty Mouse]

5 straight days in an emergency department? For $65/hr? You are absolutely crazy. Doesn't matter how many days off in a row you're getting in exchange.

 

[Antibodies]

In the end I decided to go with the lower volume, lower pay shop. There are a lot of different ways to slice it, I suppose but 40,000 of post tax income divided over a 4,000 increase in patient volume essentially works out to $10 a head in your pocket for the extra work you'd be doing. While 6,500 would be no problem volume wise single coverage, it's probably just busy enough to interrupt sleep on a regular basis. At the slower shop I can work two blocks of five 24 hour shifts in a row and have 20-21 days off in every month not named February. I'll probably get paid for sleeping a good number of the days I am at work...and if I pick up shifts at the other rural hospital a half hour down the road with half the volume of this one, I can even get paid for sleeping at home. I'm not lazy-just tired-and really looking forward to the end of residency. Oh, and I can buy a nice house for around $100k.

Does that mean you are literally living in the hospital for 5 days straight? I would assume you don't have a family?

 

[hemoglobincell]

I don't understand. Why wouldn't you find a job making $130/hr and work half as much? If lifestyle is your #1 concern, why slave yourself out at $65/hr? I mean, that's less than a PA makes.

 

[WerdSalid]

I would still try to work an occasional shift at a nearby ED as PRN just to keep your skills up...[/QUOTE]

As someone who works in a "rural" 15-17K single-coverage ED, anectotally I've never found any evidence that working in such a setting is a prelude to diminishing skills: clinical, technical or otherwise. We do have a mid-level provider but obviously no med students, residents or consultants to shoulder work / procedure burden. Your point is understood, however, given that a 6-7K volume gig would mathematically entail less procedures.

 

[Arcan57]

I would still try to work an occasional shift at a nearby ED as PRN just to keep your skills up...

As someone who works in a "rural" 15-17K single-coverage ED, anectotally I've never found any evidence that working in such a setting is a prelude to diminishing skills: clinical, technical or otherwise. We do have a mid-level provider but obviously no med students, residents or consultants to shoulder work / procedure burden. Your point is understood, however, given that a 6-7K volume gig would mathematically entail less procedures.[/QUOTE]

17k versus 2.5k is a qualitatively different experience. Single coverage at a 17k shop is 47 pts/day versus 7 pts/day at a 2.5k shop. Especially for the critical first couple of years after residency, the lack of volume, pathology, and procedures (other than splinting/suturing) is going to have an impact on what you can handle in the future.

Another way of looking at the volume is that at 10 24hr shifts/month, you'll see 2136 pts/yr at a 6500/yr shop and 821 pt/yr at the 2500/yr shop. At a 17k/yr shop that would be 5589 pts/yr. If continued for any length of time, you can't tell me that the doc that's seeing 1/7th times as many patients is going to be as skilled as the doc at the higher volume facility.