What determines your income in EM?

[mfrederi]

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I am an MSIII going into EM. I understand that there are fee for service and salaried positions, with multiple variations thereof. However, what I am curious about is how do you get the great EM jobs, i.e. fee for service, good benefit package, partnership oppurtunity. How influential is your residency programs "prestige" in getting you on the fast track to a good job? I ask this because obviously next year I will be applying to residency and want to know whether or not I should be willing to deal with some less than ideal issues in order to go to a more "big name" program (e.g. moving, less favorable schedule, less benefits, etc). What would you say the best programs are by the way? - Just kidding

 

[docB]

Good question. The main determinant of your income in EM is the payor mix of your population. If your population is predominantly uninsured you will make less. If your pop is well insured you will make more. There are a zillion other variables but that's the main factor.

Your residency doesn't matter that much in the private world. It matters more in academics. In the private world your experience and record matter more. The really hot private jobs often won't hire new grads. They want a few years of track record, speed and so on before they'll take you.

And remember what I've said on here for a long time. Compensation = pay + benefits. Bad pay and great benefits can be an excellent compensation package for many people.

 

[crewmaster1]

I am also an MSIII and have heard quite a bit about "management groups" (thoroughly discussed in the book The Rape of Emergency Medicine, a must read for any ER bound person). I have heard that it is much easier to get a job for a management group that staffs tons of ERs and scalps a chunk of profit off of your reimbursement, but if you can get into a private group that contracts directly with the hospital you make a significant amount more. How real is all this stuff I have heard about and how much does your residency affect which type of practice you get hired into? Does 3 vs 4 year residencies affect this as well?

 

[BKN]

I am also an MSIII and have heard quite a bit about "management groups" (thoroughly discussed in the book The Rape of Emergency Medicine, a must read for any ER bound person). I have heard that it is much easier to get a job for a management group that staffs tons of ERs and scalps a chunk of profit off of your reimbursement, but if you can get into a private group that contracts directly with the hospital you make a significant amount more. How real is all this stuff I have heard about and how much does your residency affect which type of practice you get hired into? Does 3 vs 4 year residencies affect this as well?

Repeat after DocB "Payor mix, payor mix, PAYOR MIX".

The Rape of Emergency Medicine is so '80s and reflects a time when most of the EPs were untrained and a fair number were losers (so were the contract holders). Today, there are contract managment groups that are exploitative, there are single holder contract holders who are exploitative, there are "Democratic Groups" that are exploitative. and vice versa.

Go get the best training you can and be the best Doctor and person that you can. Then you'll be competitive. Learn some business along the way, but the "big" decisions can wait until you are a little farther along.

BN

 

[spyderdoc]

Repeat after DocB "Payor mix, payor mix, PAYOR MIX".

The Rape of Emergency Medicine is so '80s and reflects a time when most of the EPs were untrained and a fair number were losers (so were the contract holders). Today, there are contract managment groups that are exploitative, there are single holder contract holders who are exploitative, there are "Democratic Groups" that are exploitative. and vice versa.

Go get the best training you can and be the best Doctor and person that you can. Then you'll be competitive. Learn some business along the way, but the "big" decisions can wait until you are a little farther along.

BN

Yes, payor mix is huge. We have a decent payor mix at our hospital. I would say accross the board, we bill an average of $300/pt, and collect about $130. I guess this is decent consider all comers are included in this, such as suture removals and no pays (aka uninsured/self pays).

I've been averaging around 300-320 pts/mo, so that makes for a pretty decent living......

 

[EctopicFetus]

But of the 130 you collect per patient dont you have to pay nurses and for equipment / supplies or am I missing something?

 

[crewmaster1]

Yes, payor mix is huge. We have a decent payor mix at our hospital. I would say accross the board, we bill an average of $300/pt, and collect about $130.

I've been averaging around 300-320 pts/mo, so that makes for a pretty decent living......

I did the simple math (310patients/month X 130/patient X 12 months)...are you telling me you are making about 480,000 per year as an ER doc?!? That seems crazy high...San Jose here I come!

 

[spyderdoc]

But of the 130 you collect per patient dont you have to pay nurses and for equipment / supplies or am I missing something?

No. The doctor bill is seperate from the hospital bill.

We do pay our own malpractice, life/disability, and billing company fees.

Malpractice in CA is relatively cheap. It starts at around $5k/yr, then goes up to about $18k/yr over 5 yrs and stays there.

The billing company takes 10% of the collections. Using this billing company is wonderful. They do all the coding, collecting, and everything else to get the most reimbursement possible. All I do is the charting. I think that the 10% is so worth the fee.

Life and DI are about $5k/yr through the AMA.

Most of the guys in our group are in the low to mid $400s (after group overhead and billing company expenses)

Group overhead costs are about $1k/mo or so.

Admin duties are not compensated, such as dept meetings, and committee stuff. I am on 2 committees, so not too bad....

My "buy in" to be a partner in the group is to:
1) Work 6 overnights/mo for 2 yrs, then a proportional amount thereafter
2) Full time is considered 12 shifts/mo (8hr). I like to do 14.
3) They take 20% of my take for the 1st 6mo, then 15% for the next 6 mo, then 10% for 6 mos, the 5% for the last 6 mos. At 2yrs, I will take 100% of my collections minus group overhead costs.

It is pretty straight forward. After 2 yrs, I will be partner and have my "voting rights". There is no "hanky panky" stuff going on in the group. They don't screw people over and boot them at 2 yrs. There is virtually no turn over. The reason they hired a few people over the last 2 yrs was that they built a new ED and needed more bodies, and a couple of guys retired...

We hire people a few yrs out of residency, and are actually looking for one more full timer....

Hope this info helps...

 

[turtle md]

But of the 130 you collect per patient dont you have to pay nurses and for equipment / supplies or am I missing something?

Usually, nurses, etc. are the hospital's responsibility. Am I right?

 

[turtle md]

posted same time as spyderdoc, so ? answered...

i think i'll just...

 

[EctopicFetus]

Spyderdoc.. 400K sign me up man! (shoot.. I got to match 1st)!

maybe in the future 🙂

 

[EctopicFetus]

BTW Spyder thanks for the great info!

 

[DropkickMurphy]

Good grief.....I want to work for your company once I get done with residency and get a couple of years of experience under my belt.

*looks at $2000 paycheck for this month from working per diem as an RT* 🙁 😡

 

[mfrederi]

Spyder-

OK, this sounds like a pretty good job. So, in finding a new member of your group, what are the main things you are looking for? Obviously previous experience is #1, does the caliber of residency enter into the equation? If you see that an applicant went to Denver (insert random so called prestigous residency here) does that automatically give him a leg up over the guy that went to Scott & White (a smaller EM residency in Texas), all things being equal?

Thanks

 

[spyderdoc]

Spyder-

OK, this sounds like a pretty good job. So, in finding a new member of your group, what are the main things you are looking for? Obviously previous experience is #1, does the caliber of residency enter into the equation? If you see that an applicant went to Denver (insert random so called prestigous residency here) does that automatically give him a leg up over the guy that went to Scott & White (a smaller EM residency in Texas), all things being equal?

Thanks

All residencies are equal in our eyes, but if you come from the pretigious In-n-Out Burger residency, you will be a guaranteed shoe in. Hell, we will even take these applicants straight out of residency 👍

But seriously, if you can clip along at a good pace, be somewhat nice to the patients as well as the consultants and ancillary staff, and be willing to take on some admin responsibilities, you would be a good applicant. Residency doesn't matter really. We have a few from Highland, one from Louisiana, one from Michigan, and myself from Yale.

I think keeping up with the pace is key. We have a part timer that seems to get overwhelmed, and is actually leaving the group. When you work in the fast track area, you can see 4pts/hr, but they are mostly quickies, so it is doable. On the main side you will usually around 2.5-3 pts/hr over the span of the shift.

I am happy here so far. I think it was a good move for me to leave the Kaiser system. But I must say, Kaiser is an excellent system in that you will have a decent salary with great benefits as well as a great retirement package provided to you. With my new job, I have to do my own SEP-IRA to provide my "pension", which is something like $42k/yr pretax .

I don't want to appear as if I am bragging about the salary. I am just trying to give you all an idea of what can be found out there. This type job is NOT very common, especially in a desirable living area. I am happy in that I don't feel like this is blood money. In other words, I am not living in a place that I would be unhappy and working my tail off (like some of those high paying Texas jobs that slave you to death).

In reference to this Alaska job, I am not sure how a place can pay you $600k, unless 100% of your population is well insured, or the group is getting supplemented by the hospital to recruit people.

The main scary disadvantage of my job is that every 2 yrs when our contract comes up for renewal, the big contract groups try to take over our contract. My group has had this contract for over 25yrs, so it has been relatively stable. Hopefully it will stay that way....

Well, I think that's about it for now....

Mark

 

[BklynWill]

Does anyone know of a reputable online tool that examines the payor mix of populations by state/ city?

Haven't even started rotations yet but I'm still curious...

 

[substanceP]

Learn some business along the way, but the "big" decisions can wait until you are a little farther along.
BN

Is business management taught during residency (e.g. a lecture once a week/month on business management and related topics), or is it something one is expected to learn on one's own during residency? Thanks.

 

[BKN]

Is business management taught during residency (e.g. a lecture once a week/month on business management and related topics), or is it something one is expected to learn on one's own during residency? Thanks.

Probably every program does some, but its hard to put enough into an already stuffed curriculum. You would be well advised to talk informally with the ED director, compliance officer, and guys in private practice.

 

[Hoya11]

So if a better payor mix is key, then wouldnt the best jobs be in the hospitals in the most affluent areas? Like a sleepy suburban ER in a rich town?

And does age/experience buy you anything? HOw much does 10 years experience buy you in terms of salary? Are there docs with 10+ years exp making making only 180 and wokring hard? Or do you typically increase pay with age as standard procedure?

 

[Hoya11]

Bump...ANybody???

 

[docB]

So if a better payor mix is key, then wouldnt the best jobs be in the hospitals in the most affluent areas? Like a sleepy suburban ER in a rich town?

And does age/experience buy you anything? HOw much does 10 years experience buy you in terms of salary? Are there docs with 10+ years exp making making only 180 and wokring hard? Or do you typically increase pay with age as standard procedure?

Good ?. Yes some of the best jobs are in sleepy suburban towns. The money you'll make will also be affected by census and acuity which are usually lower at the suburban spots. You can adjust for this by changing your staffing. As I said before, many of the groups that hold the sweetest contracts won't hire someone fresh out so age and experience would be needed to get in the door.

 

[NinerNiner999]

Spyderdoc - it sounds like you are in an "eat what you kill" arrangement, not based hourly. How do procedures get factored into your billing? Are they included in your $300/pt flat fee? Do you get paid any hourly differential? I've heard of buying into partership after working nights. In your group. how do nights get spread after partership and is there immediate profit sharing? I have a couple of offers out there that are set up similar to yours, I just want to see the variations...

 

[spyderdoc]

Spyderdoc - it sounds like you are in an "eat what you kill" arrangement, not based hourly. How do procedures get factored into your billing? Are they included in your $300/pt flat fee? Do you get paid any hourly differential? I've heard of buying into partership after working nights. In your group. how do nights get spread after partership and is there immediate profit sharing? I have a couple of offers out there that are set up similar to yours, I just want to see the variations...

Yes. It is completely eat what you kill. This $300 is the average billing that accounts for all pts that I see. This is not a flat fee. This is from the $0 suture removal to the $1200 critical care multi procedure pt. Yes, I bill for all procedures. Everything from reading a pulse ox and monitor strip/ECG to ortho/wound procedures.

There are no hourly shift differentials, since I am completely a fee-for-service. The only person that really gets a stipend is the chief, and that is factored in to the group overhead costs.

As far as profit sharing, it doesn't really apply to my kind of group, because I collect all the profits that I get for each patient. There is a little bit of profit that comes from the nurse practitioner's collections, but most of that goes toward group overhead costs.

As far as the nights go....After I am a partner, nights will be more proportional to the other shifts. So I should be doing 2-3 nights/mo. At this time, there is the "no nights after 51yo" rule....Hopefully, this will still be the rule when I turn 51. But even so, 2-3 nights/mo is doable.

Hope this helps.
Mark

 

[BKN]

So if a better payor mix is key, then wouldnt the best jobs be in the hospitals in the most affluent areas? Like a sleepy suburban ER in a rich town?

Sometimes true, but did you go into EM to be bored?

And does age/experience buy you anything? HOw much does 10 years experience buy you in terms of salary? Are there docs with 10+ years exp making making only 180 and wokring hard? Or do you typically increase pay with age as standard procedure?

Mostly not in groups like the one you refer to.

Salary usually goes up in academic jobs or stays stable with fewer clinical hrs/greater admin responsibility. But the academics usually make less to begin with.

 

[mountebank]

bump...good post