Well this is nice!

[TrumpetDoc]

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I too have been with a dead end cubicle EM job that saw our pay go down albeit gradually, and this was 4 yrs ago.
But so many stay for family reasons and such.
I have 3 young kids myself, but my wife and I have an understanding that if the pay drops, I go freelance.
I simply won't do this job for any less. To be honest, I am trying to figure a way to go freelance earlier as I would be able to get out that much faster.

 

[RustedFox]

At what point would doctors leave? If you had a 50K pay cut would you leave your job? How about 100K?

The problem with us in general is that we don't stick up for ourselves. I'm guilty of it too, working at a job for 5 years that paid less and less each year. Now that my eyes are open, I realize that our mobility is key for us. Any place that cuts my pay now, I'm going to leave and go elsewhere. I wish every physician would do the same and then we'd have more control.

I took a 10/hour pay cut at my new job to avoid a "raise" (albeit predicated on unachieveable metrics) at my old job. Sure, they said they would give us all a raise... and when we didn't measure up... we would take a 25% loss in pay.

I found a way to "diversify" last month. I hope that it pans out like I hope.

 

[sum dude]

I can't get that link to work, but I wonder if this is a consequence of actively encouraging people to use ERs for everything and then the hospitals and doctors taking advance of higher ER billing fees.

Free standing ERs are a perfect example of this. For many things they are no different than urgent cares, yet the charged fees are different. I'm not excusing the insurance companies because I think they are a large part of our current health care problem, but the hospitals and doctors have been taking advantage of this loophole for personal profit.

If people were paying directly for care, costs across the board would fall very quickly. Hospitals and ER groups are exploiting the system and because people aren't directly responsible for the costs, the insurance company is eating the higher cost. This is the same thing (although much less markup) as that ceo at Turing pharmaceuticals buying Daraprim and then raising the cost 5000%.

Hopefully this will mitigate the billboards with "ER wait time X minutes" and allowing people to make an appointment to the ER. If you want to advertise the ER like a glorified clinic, don't be surprised when insurance starts paying you like one.

Whoa whoa whoa
Such a complete miss-understanding of how you get paid is what is killing us. You realize ED Groups get paid below cost on 66% of our patients (Medicare, Medicaid, Self/pay/no insurance). How do you think you get your salary? Insurances are fleecing ER groups b/c they don't want to pay Usual and Customary Reimbursement. They are pretending to be "In-Network" with hospitals, while failing to contract with any physicians. We're getting paid like half of what we charge for for "maximum allowable" by insurances, and 2/3 of our patients are paying LESS THAN COST. It's ignorance like this that's killing physicians. I highly recommend you read up on the facts before spouting non-sense.

To everyone else, please read Texas Med Association primer on balance billing so you don't sound like a fool (I don't even work in Texas, they just have the best description of problem I've read). Per CDC stats, 92% of people who show up at ED had no where else to turn to. It's important doctors get with the program on this. Insurances are systematically trying to lower reimbursement to lower their costs. Banning Balance Billing, which is essentially the only leverage we have in contract negotiations, puts EM Physicians at such a systematic disadvantage, that we would essentially be better off with medicare rates. Don't believe me--look at California, where reimbursement has dropped 20-30%.

highly recommend everyone gets involved somehow with this, whether ACEP, AAEM, your state AMA, or whatever. EM doctors do not realize what a mistake they are making by not aggressively preserving their right to negotiate with insurances on this issue.

 

[sum dude]

True. But this bill along with balance billing bans could effectively make emergency medicine and specialist coverage financially unsupportable. One of two things will happen:

1. Hospitals give heavy subsidies to the CMGs to keep emergency coverage

2. The system collapses.

I suspect number one will be most likely. Smart states like Texas would be wise to not enact balance billing laws, hence keeping their doctors and attracting more.

Notice these laws are being proposed in CA (passed), IL (passed w/ terrible compromise for EM physicians), NY (decent compromise). TX, CO, and FL (where I work) are next. I've seen the bill proposed--it's initial presentation would have set basically all rates at Medicare rates (OON would have been capped at highest of Medicare, In-network, or "compromised rate", however, if no balance Billing exists, then Insurances have no incentive to make first 2 higher than medicare rate.) I can promise you that the only groups that can survive in that environment or CMG's subsidized by hospitals. At that point, there might as well be just one payor (Medicare), and we all might as well work for hospitals. Fortunately in FL, we were able to shoot it down, working through FMA, FCEP, FAAEM. The bill survived and now is back for second term. Our group ran the numbers-- if the initial bill passed, it would have resulted in 30-40% hit compensation for our physicians. Knowing what is going on, and doing something about it (give your time, money, or both!) is critical for the future of our practice.

 

[sum dude]

We are all familiar the zebras. The problem is that emergency rooms are increasingly being used for non-emergencies and are even being advertised to the public to encourage them to come for anything they want. Compare this to places like the UK where they run campaigns essentially telling people to see their gp and not waste ER resources for minor things.

If doctors and hospitals want to be able to charge more for ER visits, then stop promoting the ER as being no different than a primary care office or urgent care. The billboards with wait times, the 15 min door to doc times, allowing people to book appointments to the ER... these all have to stop. The whole purpose of an ER is to triage and treat based on priority of medical emergency. By treating everything as an emergency, nothing is.

The health care industry (doctors included) only has itself to blame. The greed has caused a system that is a failure. People can't get in to see providers and people can't afford care. People are being left untreated or bankrupt. But rather than do things like encourage mid level primary care, the physicians fight tooth and nail to protect their own interests under the guise of "patient safety" when the reality is that much routine primary care doesn't require a physician level of a care; not to mention the fact that most medical students don't even want to do primary care.

Same goes for the ER. I didn't train to be a resuscitation and trauma specialist so that I can spend my day treating things that should be seen at a walkin clinic. And before everyone says "well zebras exist!"... yes I am aware of this and part of the responsibility of the doctor is to be extremely thorough in regards to differential diagnosis. But when we act like everything must be seen right away and when we encourage people to use the ER for non-emergencies, we are making the ERS unsafe and unable to function in the capacity they were intended. The treatment of actual emergencies suffers as a result of all this.

But please let me hear more about docs routinely seeing 3pph as if there's any chance those are all actual medical emergencies and that there's even a chance the doctor is using their brain with every case to take a thorough history, perform a complete exam, consider an exhaustive differential, and perform the appropriate workup and treatment.

The fact that er docs routinely even see 3 pph is the greatest argument in favor of not paying a premium for emergency care.

I highly recommend you read the RAND report. If EMTALA and the ED doesn't exist, the US medical collapses. I'm sorry you got sold a false set of bills when you signed up for ED, but who do you think pays for your 300k+ salary? Here's a hint--it's not the the recurrent homeless cirrhotics who present w/ GI bleeds. It's the insured "worried well" w/ gastroenteritis, GERD, and migraines. If not for them, your group and hospital could not afford to take care of the crashing patients.

The truth is, our system set up as it is, there is no where else to go. PCP's can only make ends meet by seeing insured patients. Most medicaid, self-pays, and Medicare patients have no where else to go. You are the safety and linebacker at the same time. Please don't spout unverified ignorance that "majority of patients in ED don't need to be there"--that just does not exist anywhere in the world. Your job is important, and no one else is going to (or has the capacity to) do it. Own it, know your value, and demand compensation for your insight, expertise, and ability to manage chaos 24/7/365, and demand that your legislature protects the right for you to negotiate for your expertise.

 

[Apollyon]

Notice these laws are being proposed in CA (passed), IL (passed w/ terrible compromise for EM physicians), NY (decent compromise). TX, CO, and FL (where I work) are next. I've seen the bill proposed--it's initial presentation would have set basically all rates at Medicare rates (OON would have been capped at highest of Medicare, In-network, or "compromised rate", however, if no balance Billing exists, then Insurances have no incentive to make first 2 higher than medicare rate.) I can promise you that the only groups that can survive in that environment or CMG's subsidized by hospitals. At that point, there might as well be just one payor (Medicare), and we all might as well work for hospitals. Fortunately in FL, we were able to shoot it down, working through FMA, FCEP, FAAEM. The bill survived and now is back for second term. Our group ran the numbers-- if the initial bill passed, it would have resulted in 30-40% hit compensation for our physicians. Knowing what is going on, and doing something about it (give your time, money, or both!) is critical for the future of our practice.

Is there a typo in the bolded? I don't know if "or" should be "are", or if you meant to have something before the "or". Trust me, your stuff is good stuff.

 

[GeneralVeers]

Sum Dude is exactly correct in his assessment. If passed, then we will take a huge financial hit. Normally I'm gloom and doom, however we also provide an essential service which is our leverage. Hospitals, medicare, and indeed our national healthcare system relies on us. If you dry up our payments, we'll quit altogether, and fewer people will go into the specialty. That shortage, combined with our necessity will force hospitals and CMGs to subsidize our salaries. Yes we might only be making 100-200K from patient billing, but if the hospital wants to keep their ER open they are going to need to kick in the 100K subsidy to keep us working.

 

[Lord Humongus]

Sum Dude is exactly correct in his assessment. If passed, then we will take a huge financial hit. Normally I'm gloom and doom, however we also provide an essential service which is our leverage. Hospitals, medicare, and indeed our national healthcare system relies on us. If you dry up our payments, we'll quit altogether, and fewer people will go into the specialty. That shortage, combined with our necessity will force hospitals and CMGs to subsidize our salaries. Yes we might only be making 100-200K from patient billing, but if the hospital wants to keep their ER open they are going to need to kick in the 100K subsidy to keep us working.

All of Africa and Asia is ready and willing to fill up those EM residency slots...

 

[Daiphon]

All of Africa and Asia is ready and willing to fill up those EM residency slots...

...and all the APNs are chomping at the bit, which is what I fear the endgame is.

 

[Mad Jack]

Sum Dude is exactly correct in his assessment. If passed, then we will take a huge financial hit. Normally I'm gloom and doom, however we also provide an essential service which is our leverage. Hospitals, medicare, and indeed our national healthcare system relies on us. If you dry up our payments, we'll quit altogether, and fewer people will go into the specialty. That shortage, combined with our necessity will force hospitals and CMGs to subsidize our salaries. Yes we might only be making 100-200K from patient billing, but if the hospital wants to keep their ER open they are going to need to kick in the 100K subsidy to keep us working.

Or they'll do what they did to anesthesia once anesthesiologists started demanding subsidies- forced them to oversee midlevels, or replaced them with midlevels entirely. This is bad, real bad.

 

[TrumpetDoc]

Or they'll do what they did to anesthesia once anesthesiologists started demanding subsidies- forced them to oversee midlevels, or replaced them with midlevels entirely. This is bad, real bad.

This is the situation I fear will thwart what "should" be a collapse. CMGs will be key to this as will hospitals. CMGs will reach in and either demand no subsidy or significantly less promising heavy MLP staffing, lowering their costs and building their contract portfolios.
Or, just lower staffing to make docs see 4 per hour just to keep the wage they have.

Or their is a massive and public ad campaign demonstrating the "danger" of this to pts... massively increased wait times, doc shortages, etc. Come on ACEP!
Mm

 

[coachB]

This is the situation I fear will thwart what "should" be a collapse. CMGs will be key to this as will hospitals. CMGs will reach in and either demand no subsidy or significantly less promising heavy MLP staffing, lowering their costs and building their contract portfolios.
Or, just lower staffing to make docs see 4 per hour just to keep the wage they have.

Or their is a massive and public ad campaign demonstrating the "danger" of this to pts... massively increased wait times, doc shortages, etc. Come on ACEP!
Mm

Seriously? ACEP? They sold out to the CMGs long ago.

 

[TrumpetDoc]

Seriously? ACEP? They sold out to the CMGs long ago.

Oh I know...I forgot my sarcasm font:/

 

[bravotwozero]

Just got off the phone with Harry Monroe from ACEP. Told me ACEP is discussing what option to proceed with. One of them is to file a lawsuit against the government, we may have a case under the imminent domain clause of the constitution. Also told me there was a congressman from Texas that proposed legislation to ban balance billing, but is not expected to pass.

You want affordable healthcare without screwing over doctors? Get rid of insurance companies is what I say.


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[bravotwozero]

The CMGs are actually also on board with the lawsuit option via EDPMA, which deals largely with reimbursement issues


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[deleted109597]

You want affordable healthcare without screwing over doctors? Get rid of insurance companies is what I say.

Yes. This is exactly why so many of the NHS are going on strike. Because they paid so well... [/sarcasm]

 

[GeneralVeers]

Yes. This is exactly why so many of the NHS are going on strike. Because they paid so well... [/sarcasm]

I'm not sure if he meant going to single payer, or having fee-for service. I agree that single payer would be bad for us. Fee-for-service would actually be good, but it offends the progressive, social justice morality of many left-wingers.

 

[Janders]

I love FFS, and social justice! Even liberal softies can have some common sense about economics 😉

 

[bravotwozero]

I'm not sure if he meant going to single payer, or having fee-for service. I agree that single payer would be bad for us. Fee-for-service would actually be good, but it offends the progressive, social justice morality of many left-wingers.

I meant the latter. There are quite a few countries with this arrangement, and the costs of healthcare are much lower, and these are the same places that now have a thriving medical tourism industry full of US customers for precisely this reason. Turkey and Jordan come to mind. Without insurance companies meddling, the cost of healthcare goes down.


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[Lord Humongus]

So realistically, what kind of impact are we looking at here, assuming this ruling stands and that all states eventually end up banning balance billing, making relocation a moot point. Is this on the order of a 10% income cut, or a specialty-destroying asteroid?

 

[LostinLift]

So on a completely unrelated note, who is the least crazy Republican candidate right now?

 

[gutonc]

So on a completely unrelated note, who is the least crazy Republican candidate right now?

Bernie Sanders.

 

[GeneralVeers]

So realistically, what kind of impact are we looking at here, assuming this ruling stands and that all states eventually end up banning balance billing, making relocation a moot point. Is this on the order of a 10% income cut, or a specialty-destroying asteroid?

It's hard to say. The impact probably varies by state and location. It would be determined by the percentage of ED patients who are "out of network" at any one hospital. If your volume of these is low, then the impact probably won't be very much.

I suspect the reason the government made this decision was to help coerce insurance companies to stay within the Obamacare program. Key players like United Healthcare are pulling out or threatening, and this may be a carrot to convince them to keep offering losing-money plans.

 

[Perrotfish]

nvm

 

[deleted109597]

I'm not sure if he meant going to single payer, or having fee-for service. I agree that single payer would be bad for us. Fee-for-service would actually be good, but it offends the progressive, social justice morality of many left-wingers.

I'm not entirely sure FFS would be a boon for EM. The actual emergencies it wouldn't make any difference in patient selection. However, unless you were willing to get reimbursed at primary care rates, many of our patients would be hit with sticker shock and likely reassess if they actually *had* an emergency to begin with. I'm fairly certain I could decrease emergency utilization in this country by simply charging $5 upfront to park.
And remember, we would still be bound by EMTALA, so we would have to MSE patients, then give them a price list. I'm sure lots of people would then decide to leave. And heaven forbid the lawyers finding out that a patient chose not to get test X because of cost and ended up having the disease.

 

[Psai]

I'm not entirely sure FFS would be a boon for EM. The actual emergencies it wouldn't make any difference in patient selection. However, unless you were willing to get reimbursed at primary care rates, many of our patients would be hit with sticker shock and likely reassess if they actually *had* an emergency to begin with. I'm fairly certain I could decrease emergency utilization in this country by simply charging $5 upfront to park.
And remember, we would still be bound by EMTALA, so we would have to MSE patients, then give them a price list. I'm sure lots of people would then decide to leave. And heaven forbid the lawyers finding out that a patient chose not to get test X because of cost and ended up having the disease.

What's to stop the $1000 dollar taxpayer funded ambulance rides?

 

[EM_Rebuilder]

What's to stop the $1000 dollar taxpayer funded ambulance rides?

Federal tort protection for starters, and an American Public that accepts the risk a no ride brings to eventual outcomes. Any EMS Medical Director needs to feel comfortable that having their medics do a 'no ride' at the medics discretion will not allow the MD to end up in a lawsuit. Medics are good, they are and can be really GOOD. They are not doctors, they are not even 'mid levels'. There are Zebras out there. We will do a no ride on someone that we return later to find dead. That is an impossible situation to avoid. At somepoint, it becomes simple statistics...

America has to decided something. Do we want the best health care system in the country that meets each and everyone's demands, or do we want a cost efficient health care system where sometimes, you are going to be the statistic...

I also agree with the beard above on charging to park. That would have some impact, but as stated, someone in some states would sue and call that a barrier or something. Again its a statistic. Enough zebras out there to bite you...

 

[sum dude]

So realistically, what kind of impact are we looking at here, assuming this ruling stands and that all states eventually end up banning balance billing, making relocation a moot point. Is this on the order of a 10% income cut, or a specialty-destroying asteroid?

20% reimbursement cut in California (do the math, that's $60k/yr for avg. $300 k salary.) It's not like you're seeing less patients or get better liability for your paycut either.

In Florida, we had our group analyze the cut if the Balance billing ban law passed how it was originally written--it was 33-40% cuts in revenue. Basically, we would have all made Medicare rates based on original law language. Remember 1/3 of our patients pay below costs, medicare pay costs, and Insurances pay your salary.

You guys can be cynical all day about National and State ACEP and AMA (and AAEM), but in the end of the day, we were the ones meeting with State Legislature and opposing the terrible, insurance backed bill they had (and no, I don't work for CMG). They're far from perfect, but in the end, it's all we got to represent us, so give your time, give your money (preferably both), or just give up (and take it... )

 

[Old_Mil]

...i think you see that happening. The number of unfilled jobs in my former state has increased 160% since they expanded Medicaid.

...and really balance billing isn't much of a solution because you are just cost shifting from an entity that was likely to pay to one that isn't.

...and as far as the candidates, I am in favor of sending Trump to D.C. He is the closest thing to the incredible hulk I can find.

 

[bravotwozero]

...i think you see that happening. The number of unfilled jobs in my former state has increased 160% since they expanded Medicaid.

...and really balance billing isn't much of a solution because you are just cost shifting from an entity that was likely to pay to one that isn't.
.

Balance billing doesn't work because our patients are going to pay for the shifted cost. It works as a bargaining chip against the insurance companies to give ED physicians a reasonable payment. Otherwise, patient gets balance billed, and gets pissed off at their insurance company. They don't like that, especially from employers who bought into the plan.




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[GeneralVeers]

A 20-30% pay cut will have to be made up by hospital stipends in some areas. There is no alternative if hospitals want to keep their EDs open. We're certainly not at a place yet where hospitals and the general public will accept an ED run by all (or mostly) PAs.

 

[sum dude]

A 20-30% pay cut will have to be made up by hospital stipends in some areas. There is no alternative if hospitals want to keep their EDs open. We're certainly not at a place yet where hospitals and the general public will accept an ED run by all (or mostly) PAs.

Right now the CMG's are making up the difference, b/c they can shift b/n profitable states and subsidize non-profitable ones. So your options, if states ban balance billing like California, are (1) work for CMG, or (2) work for hospital. No private group will survive this. In Florida, the largest private group is already rumored to be bought out by big CMG. If they can't make it, no one will.

 

[Birdstrike]

What a crock! I am at a loss right now. I hope ACEP plans on further action beyond a letter!
Guess it may pay to know if you live in a state that has banned balanced billing.


http://newsroom.acep.org/2015-1...

Health Plans Not Required To Pay Fairly for Emergency Care, Under New Regulation
Dec 1, 2015

WASHINGTON, Dec. 1, 2015 /PRNewswire-USNewswire/ -- The federal government last week issued a new regulation that allows health insurance companies to pay doctors in emergency departments essentially whatever they like, opening the door to the possibility of reimbursements that do not even cover the costs of care. The American College of Emergency Physicians (ACEP) expressed astonishment at the ruling, given the feedback emergency physicians have given to CMS over several years, as well as the timing. Dr. Jay Kaplan, president of ACEP, said that the organization was considering legal action.

"This new ruling will significantly benefit health insurance companies at the expense of physicians, because they know hospital emergency departments have a federal mandate to care for everyone, regardless of ability to pay," said Dr. Jay Kaplan. "They will continue to shift costs onto patients and medical providers, as well as shrink the number of doctors available in plans. Instead of requiring health plans to pay fairly, this ruling guarantees that insurance companies can pay whatever they want for emergency care. If history tells us anything it's that insurance companies prefer to pay as close to nothing as possible, while building their war chest for profits and litigation."

According to the ruling, even the minimum standards of payment are "not necessary" in states that have banned balance billing. Balance billing occurs when health plans pay unreasonably low reimbursements, and physicians are forced to bill patients for the unpaid "balances" (similar to how a dentist bills). Health insurance companies have taken gross advantage of patients and emergency medical providers since the ACA, arbitrarily slashing payments to physicians by as much as 70 percent.

"This is a scary environment for patients," said Dr. Kaplan. "Insurance companies are alleging that doctors are charging too much, rather than admitting they are paying too little. This ruling by CMS unfortunately suggests that the federal government is on the side of Big Insurance rather than patients and their physicians."

In a recent poll, seven in 10 emergency physicians responding to a poll reported seeing patients with health insurance who delayed medical care because of high out-of-pocket expenses, high deductibles or high co-insurance.

The new regulation was issued by the Department of the Treasury, the Department of Labor and the Department of Health and Human Services.

Hmm..very, interesting.

 

[NinerNiner999]

Sadly, the only true economic "organizations" we have to "advocate" for us physicians are the large CMG's who stand to lose the most from these ridiculous laws. They will certainly advocate on our "behalf" to increase their bottom lines (and those of their shareholders). The voice of our specialty is gone. ACEP clearly lost this one, and has much weaker lobbying power than they advertise. Then again, I have yet to go to an ACEP convention or training conference where TeamHealth, Emcare or other subsidiaries were not the primary "sponsors" proudly touted as the "model" of our speciality.

Banning balance billing will be the death blow to the small democratic groups in those states. Sadly, the only physicians left to understand the basic financial structure of EM (or better stated have a vested interest in doing so) will come from these groups and have no choice but to work for the large CMG's who will take their contracts. These physicians will become the minority voice of righteousness for our specialty. These small groups will simply not have the bargaining power to negotiate the reimbursement rates similar to their counterparts. Also, the hospital they work for likely will have favorable rates for their facility fee reimbursement, but the physician group will not be included as alluded to above. Hospitals have no desire or need to negotiate on our behalf unless we are their employees - which has already proven to be a losing venture for most hospitals because they have no CLUE how we bill.

Physicians coming out of residency today have no clue what is in store in the next few years, and also have no clue what they are worth. They will take essentially whatever they are offered and think it is a good deal. They have been trained to analyze contracts with a fine tooth comb looking for that evil "non-compete clause," but have never been shown what they are worth. This preparation also comes from academic physicians, who have been droning on university salary for their careers and don't have the negotiating education to pass on to their residents. Those new graduates who "demand" more money due to their entitlement will be sorely disappointed as their counterparts sign away position after position with CMG "x" for the bottom 20% of our current salary range to buffer the losses of C-suite fat cats at the top of their corporate chain.

The only way we can collectively "bargain" for higher reimbursement and advocate for our care is to slow down and throughly examine each patient. This includes accurately asking each question of the ROS, physically examining each section we document, have detailed bedside discussions with our patients, order lab work as we are taught to (after a thorough examination), add additional tests as indicated based on results, use evidence-based guidelines to make clinical decisions, admit only those patients who truly need admissions. In short - be the doctors that our medicare/CMS tax dollars have funded us to be taught to be. Hospitals may not like the 4 hour length of stay for our discharged patients, the immediate drop in our admitted patients, the lost revenue due to throughput times, decreased admission volume, and the plummeting satisfaction scores, but none of these - NOT ONE OF THEM - are in the EMTALA mandate. Sounds crazy right? This couldn't possibly be how emergency medicine should be practiced!? Sadly, we have adopted our current model of throughput and LOS as our own industry standard, but virtue of our inherent desire to do what we are told, and not necessarily what is right. We have also tied our pay and salary range to this ridiculous model, and now the government drank the Kool-Aid.

If we collectively screened patients at a realistic pace of 1.5 patients per hour (or even 1 patient per hour in a high acuity shop), and did so uniformly, the shortage we have on hand would already be a health crisis that could not be repaired in the short term... BUT - patients would go elsewhere for care because they don't want to wait, hospitals would lose their sole source of their admission volumes and close their doors, and a shift in our favor would occur because only the truly sick would visit our ED's again. and we would have the work force to fill the fewer ED's that need our care.

When you flush a toilet, the water spins slowly at the top level, and as it goes down the drain, it speeds up exponentially. We as physicians have finished circling the drain and now we are all on a fantastic race to the bottom.

 

[GeneralVeers]

I can't disagree with the above but I don't see a solution in your response. I agree that we are increasingly the property of CMGs and hospitals. Short term I don't think it's all bad, as that business you describe has increased salaries as much as 100%. In exchange we have to comply with some some ethically questionable things like patient satisfaction and door-to-doc times. The problem is the long term, and no one has any clue what that will bring. I'd love it if things stayed as they are now with the salaries what they are. Unfortunately long term I think that the government and left-wing lobbies will view us as "fat cats" who need to give up what we've fought for. I've repeatedly implored all EPs to understand their value and the critical need society has for them and act accordingly. The grass will always be greener in another state, or country if we don't like what is being done where we live. BTW anyone who votes for Hillary in the upcoming election deserves what they get, and cannot complain about the predictable outcome.

 

[NinerNiner999]

I guess the solution would be to practice strictly according to EMTALA. They can mandate our screening, but can not mandate the manner in which we do it. They certainly can't mandate we do it under unsafe conditions. I agree with your philosophy Veers - don't take anything that pays less than you are worth. I'll add that that value for me has a per patient rate - not a patient per hour rate, or a LOS rate, or an admission rate, or any other derivation of what I do. That rate also includes a built-in anti-tort-reform component designed to protect me as a valuable EMTALA agent of the state so I can continue to give the appropriate EMTALA exam that my CMS-funded residency trained me to perform, while shielding me from the CMS fraud crackdown wrath I may suffer by checking the "All other systems are reviewed and negative" box on the LOS-inspired t-sheet EMR template that I am also mandated to use.

I guess, in short, the solution is for us to do what we are now mandated to do outside of patient care, while delivering the correct patient care, and following every letter of the law. In short, our services just got much more expensive, and should be expected to take longer to complete. The solution is for us to do what we are mandated and nothing more.

 

[usmleq]

I am a little unclear on what this all means, if the federal government already passed this regulation I assume it applies nationwide. What is the point of individual states passing/not passing similar bills?

 

[bravotwozero]

I am a little unclear on what this all means, if the federal government already passed this regulation I assume it applies nationwide. What is the point of individual states passing/not passing similar bills?

So the federal government passed legislation allowing insurance companies to determine payment to physicians, but which does not prohibit balance billing. At the state level, we're talking about balance billing. If that is allowed, this law won't impact you too much because that is there as a bargaining chip against insurance companies. If that's banned, our paycheck swill take a hit.


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[usmleq]

So the federal government passed legislation allowing insurance companies to determine payment to physicians, but which does not prohibit balance billing. At the state level, we're talking about balance billing. If that is allowed, this law won't impact you too much because that is there as a bargaining chip against insurance companies. If that's banned, our paycheck swill take a hit.


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Ok, so fighting this at a state level now is pointless I guess. Sum dude above was saying that in Florida fcep had successfully shot down the bill last year and were actively fighting it again this year, I guess there is no point in spending resources to fight it at a state level anymore (except to fight for balance billing at the state level)

 

[Aquar1us]

The basic premise of this is so sanity-crackingly... it's like the thinking of the people behind this is literally broken, like the neuronal chains inside their pink goo aren't connected up ...
but
This is the same maximum for-profit exploitation mentality that humanity hast towards natural resources ( mine s**t out, use it up) that is often associated with the free market and opposed by collective action. Still scary to see that turned on its head; and against the most immediately vital aspect of medicine 😱

 

[Cheese Whiz]

Apparently ACEP and AAEM are 'advocating for us' right now.

http://www.aaem.org/calendar/current-news&item=4400
http://www.acepnow.com/acep-advocating-for-you-on-balance-billing-and-fair-payment-issues/

no other updates

 

[Old_Mil]

This is the same maximum for-profit exploitation mentality that humanity hast towards natural resources ( mine s**t out, use it up) that is often associated with the free market and opposed by collective action. Still scary to see that turned on its head; and against the most immediately vital aspect of medicine 😱

...except in this case Gordon Gecko is the government. There is a really good book out right now, "Stealing America". It is worth a read.

 

[Aquar1us]

...except in this case Gordon Gecko is the government.

just to clarify, that is what I meant as well. That's why I said "turned on its head"

 

[BAM!]

Out of curiosity, how will this new regulation affect doctors working for HMOs, such as Kaiser?

For example, a Kaiser doc in California (with banned balance billing) is paid a salary by the HMO group. Likely they don't have as much of a need for balance billing as most the patients are Kaiser members. Of course the HMO group could get lower reimbursement from non-Kaiser patients which could lead to lower ED doc salaries.

On the flip side, Kaiser could likely reimburse less to patients visiting non-Kaiser hospitals. This would make Kaiser richer, and perhaps increase Kaiser ED doc salaries if they could leverage it somehow. Thoughts?

 

[exsanguination]

Man this is pretty depressing, especially as a current resident. Really seems like this field is heading down the tubes. Hopefully at least for the next 10-15 years we'll be able to at least command reasonable salaries in the sticks/boonies/BFE. The kind of hourly rates I see even 1 hour outside of the big cities are fairly atrocious.

I suppose I should look at the silver lining - at least I'll be able to eat, have a roof, and be able to supervise 4 midlevels. Anesthesia here we come!

(the best part is that we saw exactly how it happened with gas and here we are now. completely and utterly POWERLESS to stop it)

I'll actually be going to a talk soon where Jay Kaplan is coming by.. I think I may just ask him directly what/who exactly is being lobbied and where do we currently stand

 

[deleted480308]

I hope you guys win....I don't really want to be a surgeon

 

[AmericaAmerica]

http://www.healthcarefinancenews.com/news/new-yorks-no-surprises-law-takes-hold-end-balance-billing

This article says NY ACEP was involved in the deliberations of the NY law involving balanced billing and that they basically support it.

Can anyone elaborate on this and where ACEP stands in their lobbying efforts?

 

[BAM!]

http://www.healthcarefinancenews.com/news/new-yorks-no-surprises-law-takes-hold-end-balance-billing

This article says NY ACEP was involved in the deliberations of the NY law involving balanced billing and that they basically support it.

Can anyone elaborate on this and where ACEP stands in their lobbying efforts?

The article explains that in the event of a reimbursement-dispute between the provider and insurance company, an independent company will step in to aid in the resolution process. However, with these new December provisions it seems that the insurance companies can pay whatever they want without being held to an independent appeals process. Big loss for us.

My fear has already been stated. An out-of-network patient walks into my ED, I have to see them because of EMTALA. And I see them for free, they pay nothing, insurance pays nothing. Then they sue me for a bad outcome regardless of the care I provided.

Can we at least pass some legislation that would limit malpractice pay-outs in this situation to your maximum malpractice coverage? Or perhaps a "Good Samaritan" type argument might carry some weight (perhaps a stretch), as this is somewhat akin to treating a passerby motorist. Especially if the out-of-network insurance company pays nothing.

Obviously it's too soon to have seen any effects of this in our finances yet. For states with rules against balance billing. When do you think we will? 2 months?

 

[GeneralVeers]

Can we at least pass some legislation that would limit malpractice pay-outs in this situation to your maximum malpractice coverage? Or perhaps a "Good Samaritan" type argument might carry some weight (perhaps a stretch), as this is somewhat akin to treating a passerby motorist. Especially if the out-of-network insurance company pays nothing.

Obviously it's too soon to have seen any effects of this in our finances yet. For states with rules against balance billing. When do you think we will? 2 months?

We've tried the good Samaritan and EMTALA-carve-outs before. Essentially the Democrats are nearly in lockstep in their opposition to it and any bill would almost certainly be vetoed by Hillary. The trial lawyers spend a lot more than we do supporting political campaigns and money talks in our process.

This year we were lobbying Harry Reid (my home state of NV has a specialist-on-call crisis right now) and he was completely unsupportive. Just remember when you vote and/or donate to campaigns this season which party is entirely opposed to all of our interests.

 

[RG3forPresident]

So as a MS3 interested in EM, is this specialty shattering in terms of reimbursement? Let's assume that all 50 states ban balance billing as a worst case scenario. Combined with this new rule, will this completely destroy EM physician salaries?

I know money isn't the most important thing in choosing a field, and it's not, but I have to look at all aspects of a specialty before going into it. And this seems really bad.