What's the inside word these days at USACS, Envision, and other PE-owned goliaths?

[BoardingDoc]

I wonder if the best of both worlds would be a hourly approach with a minimum pt/hr requirement. Or maybe a hybrid model. I see lots of terrible medicine in an RVU approach. I currently work at a 100% RVU place and 100% salary place and it's quite remarkable how doctors can't seem to settle on practicing proper medicine. They either do too much or do too little.

Terrible medicine in what way? I have worked in both hourly and a purely RVU model and I have not found a huge disparity in the practice patterns in the docs between one shop and the other. I definitely noticed that people run significantly more tests/place way more consults in a academic environment on average but that seems to hold true whether they are hourly or RVU based.

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[DoctwoB]

Thank you, very much.

The only thing I might update from that post would be that not all surgical subspecialists are immune any longer. Many have voluntarily placed themselves at the bottom of the totem pole by choosing employee status, working directly for hospitals. At that point they're no longer a "customer" that brings business to the hospital. Instead, they become highly paid hotdog vendors, as mere replaceable cogs, who neither bring, nor leave, with any business of their own.

Id argue the hospital employed outpatient doc/surgeon in a middle ground and is still more of a customer. They are vendors for the hospital, but (partially depending on your states non compete laws), if they leave they make take their patients (and their OR business) with them.

 

[Birdstrike]

Id argue the hospital employed outpatient doc/surgeon in a middle ground and is still more of a customer. They are vendors for the hospital, but (partially depending on your states non compete laws), if they leave they make take their patients (and their OR business) with them.

Certainly more than an Emergency Physician working in a hospital.

 

[Backpack234]

Your missing the point in your gloom/doom narrative.

Can you move and work at a competitive city tomorrow - of Course not. But you can still move to 90% of the US and work within an hrs drive.

Point being it takes finding a job to do EM, and your income will be high on day one. Most other fields require recreating your practice which can take years.

Where can I go to move within an hours drive of Tampa?

 

[RustedFox]

Where can I go to move within an hours drive of Tampa?

I'll field this one for you.

Nowhere that's hiring.

 

[Fox800]

It should also be noted that NZ salaries are based on years of experience as an attending, it's on a stepwise scale through a nationwide collective bargaining agreement.

As a new attending, you're looking at about $135-140k USD pre-tax, which works out to about $85k-90k USD after NZ taxes are taken out. As a mid-career or late-career attending, you make quite a bit more.

Their senior residents that supervise the ED overnight have been in residency training for 5-6 years.

 

[thegenius]

Terrible medicine in what way? I have worked in both hourly and a purely RVU model and I have not found a huge disparity in the practice patterns in the docs between one shop and the other. I definitely noticed that people run significantly more tests/place way more consults in a academic environment on average but that seems to hold true whether they are hourly or RVU based.

1. too many tests
2. too little time with patients
3. too many admissions
4. too much stuff that doesn't change management

In my opinion it's much worse in an all RVU environment because now the primary thing that matters is making money.

I'm not saying an hourly model is a better way to practice. I don't know what is. They both have problems.

 

[EctopicFetus]

10 year march baby, 10 year march to freedom. Less if any of the startups i put money in go big.

You better shrink that timeline into under 5 years.

 

[EctopicFetus]

This vendor and customer example is also very relevant for my specialty—PM&R. Thanks for sharing.

And we aren’t the customers. Fu money quick.

Have you guys checked out the other site talking about the trash USACS deal with Apollo. No one wanted their POS stock i guess.

 

[RustedFox]

Have you guys checked out the other site talking about the trash USACS deal with Apollo. No one wanted their POS stock i guess.

link?

 

[EctopicFetus]

link?

Emdocs or the other EP forum. Dont know how to link from there.

New York, February 24, 2021 -- Moody's Investors Service ("Moody's") assigned a B2 Corporate Family Rating and B2-PD Probability of Default Rating to U.S. Acute Care Solutions, LLC ("USACS"). Moody's also assigned a B2 rating to the company's proposed senior secured notes. The outlook is stable.



Proceeds from the proposed $375 million secured notes along with additional $466 million preferred equity financing from Apollo Management L.P, the new private equity (PE) investor, will be used to pay existing debt, purchase a portion of outstanding shares and cover transaction-related expenses. As a result of this transaction, the current PE investor, Welsh, Carson, Anderson & Stowe will sell all of its stake in the company.



The following ratings were assigned:



Issuer: U.S. Acute Care Solutions, LLC

Corporate Family Rating of B2

Probability of Default Rating of B2-PD

Proposed $375 million senior secured notes due 2026 of B2 (LGD3)



Outlook action:

Issuer: U.S. Acute Care Solutions, LLC

Outlook assigned stable.



RATINGS RATIONALE



The B2 CFR reflects USACS' market position as the fourth largest emergency department physician staffing provider, high financial leverage, and material execution risk associated with an active debt-funded acquisition strategy. Further, USACS has some geographic concentration with Texas, Maryland and Ohio representing approximately 50% of business volumes. Moody's estimates that the company's proforma debt/EBITDA at the close of the refinancing transaction, including certain add-backs for transaction expenses on COVID-related one-time expenses, will approximate 5.0 times.



The B2 CFR is supported by USACS' strong competitive position in the markets where it operates. The company has relationships with approximately half of the top ten health systems in the US. In USACSs rating, Moody's incorporates the benefits of USACS' ownership model, in which the physicians own a significant stake in the company. This results in high alignment between the interests of the company and its physician-owners. However, these benefits are partially offset by the risk that the company (which is a non-public company) will need to "buy out" physicians who seek to retire or otherwise leave the organization, possibly by issuing debt.



Moody's notes that a very significant portion of USACS' capital structure is provided by the $466 million in perpetual, redeemable preferred stock. These securities provide a strong loss-absorption cushion to creditors in the event of default. However, if the company's restricted payment capacity (as defined in the notes offering memorandum) allows, the company has an option to redeem its preferred shares between the third and fifth anniversaries of the proposed refinancing transaction. Moreover, Apollo also has the right to request full redemption of its preferred share investment beginning in year 6. If USACS is unable to redeem the preferred shares fully after five years, its cost of using the preferred capital provided by Apollo will increase substantially, and Apollo can force the sale of the company. Consequently, Moody's recognizes the likelihood of a material change in the company's capital structure starting from the third -- but more likely following the fifth -- anniversary of the proposed transaction. Depending on how the company's capital structure evolves, Moody's will update its credit analysis accordingly.



The rating also reflects the company's good liquidity profile. This liquidity assessment is supported by Moody's expectations of $5-$10 million in free cash flow in the next 12 months as well as cash balances of approximately $20 million at the end of March 2021. It also reflects Moody's expectation of full availability under the company's $75 million senior secured first lien revolver (unrated).



The stable outlook reflects Moody's expectation that the company will continue its expansion while employing a balanced growth strategy and keeping leverage in 4.5 - 6.0 times range.



Moody's regards the coronavirus outbreak as a social risk under its ESG framework, given the substantial implications for public health and safety. In addition, as a provider of emergency room staffing to hospitals, USACS faces high social risk. The No Surprise Act, which was signed into law in December 2020, will take the patient out of the provider-payor dispute. The inability to bill out-of-network patients for amounts over in-network rates will impact those companies that have sizeable out-of-network revenues. The extent to which each company will be impacted will depend on the percentage of out-of-network patients they treat and their specific billing and collections practices, including how often they balance bill and how aggressively they pursue collecting these balances. Moody's expects the company's financial policies to remain aggressive reflecting the PE sponsor's (Apollo Management L.P) significant preferred equity investment. However, since the physicians will control the vast majority of the common equity stake in the company, they will also have a material influence in deciding the company's policies. Moody's does not consider the environmental component of ESG material to the overall credit profile of the issuer.

 

[Backpack234]

Just a thought here that seems to fit in this thread.....What is preventing docs from joining together to form their own SDG and try to retake some of the hospital contracts we lost? It seems like a major influence on CMG contracts is the partnerships/joint ventures they have with hospital systems. USACS/Advent, Envision/HCA, etc. But there are still a number of smaller, privately owned hospitals out there that employ CMGs.

What barriers exist for a group of docs that want to offer the contract a different way of doing things that could potentially be better for the hospital, the patients, and the physicians? And has anyone successfully done this?

 

[JacobMcCandles]

Just a thought here that seems to fit in this thread.....What is preventing docs from joining together to form their own SDG and try to retake some of the hospital contracts we lost? It seems like a major influence on CMG contracts is the partnerships/joint ventures they have with hospital systems. USACS/Advent, Envision/HCA, etc. But there are still a number of smaller, privately owned hospitals out there that employ CMGs.

What barriers exist for a group of docs that want to offer the contract a different way of doing things that could potentially be better for the hospital, the patients, and the physicians? And has anyone successfully done this?

Scale is a big part of it. It would also be incredibly hard for a new SDG to get their foot in the door.

 

[Arcan57]

Just a thought here that seems to fit in this thread.....What is preventing docs from joining together to form their own SDG and try to retake some of the hospital contracts we lost? It seems like a major influence on CMG contracts is the partnerships/joint ventures they have with hospital systems. USACS/Advent, Envision/HCA, etc. But there are still a number of smaller, privately owned hospitals out there that employ CMGs.

What barriers exist for a group of docs that want to offer the contract a different way of doing things that could potentially be better for the hospital, the patients, and the physicians? And has anyone successfully done this?

So any CMG contract worth it's salt is going to have a non-compete clause which basically says that you can't work at the hospital you're working at if the CMG loses the contract unless the hospital pays the CMG some dollar figure/doc to release them from the non-compete. For moderate to large size groups, this represents a 7-8 digit figure .

 

[bravotwozero]

You better shrink that timeline into under 5 years.

I wish I could man. I'd have to double the amount invested monthly, which would be 20k for me. Not realistic.

 

[EctopicFetus]

Scale is a big part of it. It would also be incredibly hard for a new SDG to get their foot in the door.

Need support. Few docs left with the skills to run a group. WOuld have to get a group of people together and partner ahead of time with a billing company or AAEM-Physicians Group.

 

[Arcan57]

Need support. Few docs left with the skills to run a group. WOuld have to get a group of people together and partner ahead of time with a billing company or AAEM-Physicians Group.

Other issue is that any group of reasonable size is going to start looking like a CMG as it expands. Dealing with a hospital system is a full time job, and once the person at the top isn’t working appreciable shifts in the ED then their interests start diverging from the pit doc.

 

[thegenius]

Other issue is that any group of reasonable size is going to start looking like a CMG as it expands. Dealing with a hospital system is a full time job, and once the person at the top isn’t working appreciable shifts in the ED then their interests start diverging from the pit doc.

Yea I can see this happening, absolutely.

 

[BoardingDoc]

1. too many tests
2. too little time with patients
3. too many admissions
4. too much stuff that doesn't change management

In my opinion it's much worse in an all RVU environment because now the primary thing that matters is making money.

I'm not saying an hourly model is a better way to practice. I don't know what is. They both have problems.

Interesting. I've worked in both pure hourly and pure rvu shops. If anything, the hourly shop culture was ordering a ton of tests/consults. That said, the hourly shop was an academic one, so maybe that factored in? I can also say that I certainly didn't spend more time in the room with patients in the hourly place than in the rvu one.

Admission rate was not visibly affected one way or the other.

Too much time on stuff that doesn't change management was absolutely higher in the hourly place, though again, I suspect that was due to the academic center bureaucracy.

I do certainly pay more attention to charting at my rvu place for obvious reasons.

All of that said, I could certainly see your concerns coming to fruition in certain rvu shops, just like you'll get patients piling up and waiting to be seen while the doc takes a lunch break in the hourly gig. I will freely admit that I moved a good bit slower at the hourly place.

 

[GeneralVeers]

Can't compare RVU place with an academic salaried place. Two different planets completely.

 

[thegenius]

Interesting. I've worked in both pure hourly and pure rvu shops. If anything, the hourly shop culture was ordering a ton of tests/consults. That said, the hourly shop was an academic one, so maybe that factored in? I can also say that I certainly didn't spend more time in the room with patients in the hourly place than in the rvu one.

Admission rate was not visibly affected one way or the other.

Too much time on stuff that doesn't change management was absolutely higher in the hourly place, though again, I suspect that was due to the academic center bureaucracy.

I do certainly pay more attention to charting at my rvu place for obvious reasons.

All of that said, I could certainly see your concerns coming to fruition in certain rvu shops, just like you'll get patients piling up and waiting to be seen while the doc takes a lunch break in the hourly gig. I will freely admit that I moved a good bit slower at the hourly place.

Unless the same ER shifts from RVU to hourly (or the other way around), I think it's too hard to compare one ER that is hourly to another ER that is RVU. There are too many confounding variables to adjust for. Currently I work for Kaiser and another non-Kaiser hospital system and it's day and night the kind of patients we get coming through both ER's

At my RVU place, we have docs that sign up for patients, walk into the room, introduce themselves, get a one liner from the patient, put in orders and say "I just want to get things started, I'll be back later to ask a few more questions" and then move to the next room to get the RVUs from the next patient. They will see 6 patients in 30 minutes. Invariably they don't go back in in some cases, and just practice medicine by looking at vital signs and lab results. It's thoroughly disgusting and a terrible way to practice.

At my hourly place, there were some docs who were so slow that they instituted a computerized patient assignment system. So you get assigned patients as they come in. That was the only way they felt they could get around that problem. There were a handful of docs who would see 1/2 the standard PPH of the other docs.

I don't think anything compares to academics, especially a residency program. It's just not the same.

I spend more time with patients at the hourly place because I only see 1/hr there (that is average for all docs). At my RVU place I'm 2/hr and I can't talk to them the way I want to.

Anyway I think it's good on you that it appears you practice generally the same way at both places. Maybe a bit slower at the hourly but that is to be understood.

 

[sloh]

Unless the same ER shifts from RVU to hourly (or the other way around), I think it's too hard to compare one ER that is hourly to another ER that is RVU. There are too many confounding variables to adjust for. Currently I work for Kaiser and another non-Kaiser hospital system and it's day and night the kind of patients we get coming through both ER's

At my RVU place, we have docs that sign up for patients, walk into the room, introduce themselves, get a one liner from the patient, put in orders and say "I just want to get things started, I'll be back later to ask a few more questions" and then move to the next room to get the RVUs from the next patient. They will see 6 patients in 30 minutes. Invariably they don't go back in in some cases, and just practice medicine by looking at vital signs and lab results. It's thoroughly disgusting and a terrible way to practice.

At my hourly place, there were some docs who were so slow that they instituted a computerized patient assignment system. So you get assigned patients as they come in. That was the only way they felt they could get around that problem. There were a handful of docs who would see 1/2 the standard PPH of the other docs.

I don't think anything compares to academics, especially a residency program. It's just not the same.

I spend more time with patients at the hourly place because I only see 1/hr there (that is average for all docs). At my RVU place I'm 2/hr and I can't talk to them the way I want to.

Anyway I think it's good on you that it appears you practice generally the same way at both places. Maybe a bit slower at the hourly but that is to be understood.

How do you feel about Kaiser overall? Upsides and downsides?

 

[thegenius]

How do you feel about Kaiser overall? Upsides and downsides?

Overall positive. At least where I work we 1) don't have midlevels, 2) a full complement of specialty services however sometimes we have to talk to Neurosurgeons or Pediatrics from other Kaiser campuses in different counties, 3) patients who have a normal or high IQ - generally that means I can reason with them, 4) it's well staffed, 5) my ER is chock full of the fanciest ER stuff you could want. 6) pay is not great but it's not bad. If you are full time you get the golden handcuffs.

The things I don't like 1) more scutwork than normal. If I need to call the Neurosurgeon in the other county I have to make a call to the operator, then I dial something else, then I get put on hold, all this nonsense. I just want to know that the doc is there. 2) I have to fill out a lot more needless paperwork (EMTALA, etc.) than normal, 3) nurses don't accept verbal orders for some reason, 4) we can't use propofol, 5) we need two docs to do conscious sedations / reductions, 6) we have a lot more cumbersome protocols for working up chest pain, renal colic, sepsis, etc. than the average hospital.

 

[southerndoc]

At my RVU place, we have docs that sign up for patients, walk into the room, introduce themselves, get a one liner from the patient, put in orders and say "I just want to get things started, I'll be back later to ask a few more questions" and then move to the next room to get the RVUs from the next patient. They will see 6 patients in 30 minutes. Invariably they don't go back in in some cases, and just practice medicine by looking at vital signs and lab results. It's thoroughly disgusting and a terrible way to practice.

This is likely to become more of a challenge to work this way with implementation of the CURES Act. Patients will see things documented that didn't occur or weren't asked, and docs may find themselves defending fraud claims against insurers and CMS.

 

[emergentmd]

At my RVU place, we have docs that sign up for patients, walk into the room, introduce themselves, get a one liner from the patient, put in orders and say "I just want to get things started, I'll be back later to ask a few more questions" and then move to the next room to get the RVUs from the next patient. They will see 6 patients in 30 minutes. Invariably they don't go back in in some cases, and just practice medicine by looking at vital signs and lab results. It's thoroughly disgusting and a terrible way to practice.

At my hourly place, there were some docs who were so slow that they instituted a computerized patient assignment system. So you get assigned patients as they come in. That was the only way they felt they could get around that problem. There were a handful of docs who would see 1/2 the standard PPH of the other docs.

This is when your partners police each other. If the director doesn't do anything about it, then a quick "personal talk" is all it takes.

I have worked in sites that were predominately RVUs and there are some docs that will cherry pick but for the most part they eventually fall in line. They just make themselves miserable by staying late charting anyhow. Just not worth it and eventually they see it.

I was offered my 1st attending job without RVUs where there were a Doc A rack and Doc B rack. Rack A was empty and Rack B was full. I walked out of the interview thinking that must be the most toxic environment. Imagine if you are Doc A and Doc B has a full rack who just went to lunch.

 

[namethatsmell]

Overall positive. At least where I work we 1) don't have midlevels, 2) a full complement of specialty services however sometimes we have to talk to Neurosurgeons or Pediatrics from other Kaiser campuses in different counties, 3) patients who have a normal or high IQ - generally that means I can reason with them, 4) it's well staffed, 5) my ER is chock full of the fanciest ER stuff you could want. 6) pay is not great but it's not bad. If you are full time you get the golden handcuffs.

I interviewed with Kaiser once upon a time and was shocked by how well-resourced the place was. These guys had lots of toys, could get an MRI done 24/7 within 2-3hrs, and there was a hospitalist basically sitting there waiting to admit patients.

I recall them talking about the handcuffs, but I forget--how many years do you need to stay before you're eligible for their pension?

The things I don't like 1) more scutwork than normal. If I need to call the Neurosurgeon in the other county I have to make a call to the operator, then I dial something else, then I get put on hold, all this nonsense. I just want to know that the doc is there. 2) I have to fill out a lot more needless paperwork (EMTALA, etc.) than normal, 3) nurses don't accept verbal orders for some reason, 4) we can't use propofol, 5) we need two docs to do conscious sedations / reductions, 6) we have a lot more cumbersome protocols for working up chest pain, renal colic, sepsis, etc. than the average hospital.

Some of that sounds onerous, but honestly I get why docs really like working for Kaiser. I also get why docs don't like working for them. At most jobs there's some component of a $h*t sandwich you gotta eat (true both in and out of medicine). I've found that pay tends to be uncorrelated with this. Anyway, the good news is that if you have a few job options, you can consider what they pay and then pick your quantity of said $h*t and the kind of bread it's served to you on (think of this as the level of support--or lack of support --from the environment you work in)....[warning, Laphroaig on board]....

Working at a typical HCA shop: High turd to bread ratio. And what little bread exists is generally toxic and it's purpose is to swiftly kill your soul if the poop doesn't.

Working at a typical CMG shop: The nuggets tend to be similar, but served up on variable types of bread. The bread won't always kill you quick, but it may kill you slow. Important to note that the bread can shrink in size at a moment's notice and then you'll be told you're now expected to see 3.5pph and then questioned if your PG scores dip as a result.

Working at a cush freestanding (and perhaps one you own): Minimal brown stuff, and the bread is actually a delicious croissant. Most of the time it works out pretty well for ya. But the flip-side is that this pastry is delicate and may have minimal reserve to withstand stressors. It may randomly flake out and crumble away, leaving you hanging out to dry.

Working at Kaiser, VA, a non-toxic hospital employed or academic place, IHS, etc: there's definitely poo but it's on a substantial, crunchy baguette. If you can come to peace with aspects of how the filling is made, that strong bread will often protect you from bigger evils looking to extract a pound of flesh from you (ie being removed from the schedule without valid cause, CMG taking your contract, ambo chasers/lawsuits, frivolous board complaints, etc). And over time you may get some perks only available to those who munch on this type of sandwich (protected teaching/research/admin time, interesting non-clinical jobs within the system, long-term health benefits, unique retirement vehicles, pension, etc).

Working as a partner at a true SDG: congratulations, you've been able to ditch these crap sandwiches for a delicious cheeseburger. But beware...now all the CMG goons are plotting to mug you for that burger and you're also at the beck and call of c-suite who can swat that all-beef patty out of your hands if you don't kiss every patient on their way out of the ER. But then again, who cares? You have the tastiest treat in the neighborhood.

 

[clibby]

I interviewed with Kaiser once upon a time and was shocked by how well-resourced the place was. These guys had lots of toys, could get an MRI done 24/7 within 2-3hrs, and there was a hospitalist basically sitting there waiting to admit patients.

I recall them talking about the handcuffs, but I forget--how many years do you need to stay before you're eligible for their pension?




Some of that sounds onerous, but honestly I get why docs really like working for Kaiser. I also get why docs don't like working for them. At most jobs there's some component of a $h*t sandwich you gotta eat (true both in and out of medicine). I've found that pay tends to be uncorrelated with this. Anyway, the good news is that if you have a few job options, you can consider what they pay and then pick your quantity of said $h*t and the kind of bread it's served to you on (think of this as the level of support--or lack of support --from the environment you work in)....[warning, Laphroaig on board]....

Working at a typical HCA shop: High turd to bread ratio. And what little bread exists is generally toxic and it's purpose is to swiftly kill your soul if the poop doesn't.

Working at a typical CMG shop: The nuggets tend to be similar, but served up on variable types of bread. The bread won't always kill you quick, but it may kill you slow. Important to note that the bread can shrink in size at a moment's notice and then you'll be told you're now expected to see 3.5pph and then questioned if your PG scores dip as a result.

Working at a cush freestanding (and perhaps one you own): Minimal brown stuff, and the bread is actually a delicious croissant. Most of the time it works out pretty well for ya. But the flip-side is that this pastry is delicate and may have minimal reserve to withstand stressors. It may randomly flake out and crumble away, leaving you hanging out to dry.

Working at Kaiser, VA, a non-toxic hospital employed or academic place, IHS, etc: there's definitely poo but it's on a substantial, crunchy baguette. If you can come to peace with aspects of how the filling is made, that strong bread will often protect you from bigger evils looking to extract a pound of flesh from you (ie being removed from the schedule without valid cause, CMG taking your contract, ambo chasers/lawsuits, frivolous board complaints, etc). And over time you may get some perks only available to those who munch on this type of sandwich (protected teaching/research/admin time, interesting non-clinical jobs within the system, long-term health benefits, unique retirement vehicles, pension, etc).

Working as a partner at a true SDG: congratulations, you've been able to ditch these crap sandwiches for a delicious cheeseburger. But beware...now all the CMG goons are plotting to mug you for that burger and you're also at the beck and call of c-suite who can swat that all-beef patty out of your hands if you don't kiss every patient on their way out of the ER. But then again, who cares? You have the tastiest treat in the neighborhood.

After reading this, all I can say is way to live up to the username! You really painted a picture there that I could smell as I read it.

 

[xaelia]

It should also be noted that NZ salaries are based on years of experience as an attending, it's on a stepwise scale through a nationwide collective bargaining agreement.

As a new attending, you're looking at about $135-140k USD pre-tax, which works out to about $85k-90k USD after NZ taxes are taken out. As a mid-career or late-career attending, you make quite a bit more.

Their senior residents that supervise the ED overnight have been in residency training for 5-6 years.

There are a lot of disincentives for fresh docs to come over, pay being just one of them.

If you're just doing it for a year's adventure, no big deal. If you hope to live here indefinitely, you'll have to fulfil the various criteria for vocational registration + probably FACEM. FACEM tends to look down on the shorter training in the U.S., and will probably need you to do jump through some extra supervisory hoops. Then, a lot of NZ (and AUS) is fairly rural medicine and may have you doing a lot of things you might have considered nurse/tech scope of practice. It's not good or bad, just different.

The salary base you're quoting is technically accurate – but there are modifiers on top of 1.0 FTE called "job sizing" that can increase your FTE above 1.0 (or, if you're at a lower FTE, boost your pay up to 1.0). Then, weekend, holiday, and evening hours all pay 1.5x base. It turns out to be OK once you're a bit out from board certification when you put it in the context of the leave accumulated and other perks in the contract negotiated by the doctor's union.

But.

Not a thread about NZ – I introduced the description of my practice just to illustrate how much acute care can be delivered by a combination of nurses and lower-trained docs being overseen by a handful of senior docs. If the compensation structure ever gets away from fee-for-service and the value of a doc is no longer justified by ability to generating billing revenue, I wouldn't doubt these jobs will get squeezed.

 

[sloh]

3) patients who have a normal or high IQ - generally that means I can reason with them.

This is really underappreciated. A lot of the frustrations from interacting with patients (in many specialties) is because they can’t “adult,” as [mention]RustedFox [/mention] would say—and a lot of that stems from IQ.

Thanks for your feedback about Kaiser. I wanted to see what the experience was like for EM docs since it’s very specialty specific. FM docs burn out at a fast clip there. I’m PM&R and worked there for about 1 year. It wasn’t for me. It seems like chronic pain disproportionately attracts those who can’t “adult.” Throw inbox/phone call responsibilities (uncompensated) on top of that sh** sandwich.

 

[KGflyboy]

Anyway, the good news is that if you have a few job options, you can consider what they pay and then pick your quantity of said $h*t and the kind of bread it's served to you on (think of this as the level of support--or lack of support --from the environment you work in)....[warning, Laphroaig on board]....

Working at a typical HCA shop: High turd to bread ratio. And what little bread exists is generally toxic and it's purpose is to swiftly kill your soul if the poop doesn't.

Working at a typical CMG shop: The nuggets tend to be similar, but served up on variable types of bread. The bread won't always kill you quick, but it may kill you slow. Important to note that the bread can shrink in size at a moment's notice and then you'll be told you're now expected to see 3.5pph and then questioned if your PG scores dip as a result.

Working at a cush freestanding (and perhaps one you own): Minimal brown stuff, and the bread is actually a delicious croissant. Most of the time it works out pretty well for ya. But the flip-side is that this pastry is delicate and may have minimal reserve to withstand stressors. It may randomly flake out and crumble away, leaving you hanging out to dry.

Working at Kaiser, VA, a non-toxic hospital employed or academic place, IHS, etc: there's definitely poo but it's on a substantial, crunchy baguette. If you can come to peace with aspects of how the filling is made, that strong bread will often protect you from bigger evils looking to extract a pound of flesh from you (ie being removed from the schedule without valid cause, CMG taking your contract, ambo chasers/lawsuits, frivolous board complaints, etc). And over time you may get some perks only available to those who munch on this type of sandwich (protected teaching/research/admin time, interesting non-clinical jobs within the system, long-term health benefits, unique retirement vehicles, pension, etc).

Working as a partner at a true SDG: congratulations, you've been able to ditch these crap sandwiches for a delicious cheeseburger. But beware...now all the CMG goons are plotting to mug you for that burger and you're also at the beck and call of c-suite who can swat that all-beef patty out of your hands if you don't kiss every patient on their way out of the ER. But then again, who cares? You have the tastiest treat in the neighborhood.

So true. You should give this presentation to residents before they seek their first jobs.

 

[Birdstrike]

I interviewed with Kaiser once upon a time and was shocked by how well-resourced the place was. These guys had lots of toys, could get an MRI done 24/7 within 2-3hrs, and there was a hospitalist basically sitting there waiting to admit patients.

I recall them talking about the handcuffs, but I forget--how many years do you need to stay before you're eligible for their pension?




Some of that sounds onerous, but honestly I get why docs really like working for Kaiser. I also get why docs don't like working for them. At most jobs there's some component of a $h*t sandwich you gotta eat (true both in and out of medicine). I've found that pay tends to be uncorrelated with this. Anyway, the good news is that if you have a few job options, you can consider what they pay and then pick your quantity of said $h*t and the kind of bread it's served to you on (think of this as the level of support--or lack of support --from the environment you work in)....[warning, Laphroaig on board]....

Working at a typical HCA shop: High turd to bread ratio. And what little bread exists is generally toxic and it's purpose is to swiftly kill your soul if the poop doesn't.

Working at a typical CMG shop: The nuggets tend to be similar, but served up on variable types of bread. The bread won't always kill you quick, but it may kill you slow. Important to note that the bread can shrink in size at a moment's notice and then you'll be told you're now expected to see 3.5pph and then questioned if your PG scores dip as a result.

Working at a cush freestanding (and perhaps one you own): Minimal brown stuff, and the bread is actually a delicious croissant. Most of the time it works out pretty well for ya. But the flip-side is that this pastry is delicate and may have minimal reserve to withstand stressors. It may randomly flake out and crumble away, leaving you hanging out to dry.

Working at Kaiser, VA, a non-toxic hospital employed or academic place, IHS, etc: there's definitely poo but it's on a substantial, crunchy baguette. If you can come to peace with aspects of how the filling is made, that strong bread will often protect you from bigger evils looking to extract a pound of flesh from you (ie being removed from the schedule without valid cause, CMG taking your contract, ambo chasers/lawsuits, frivolous board complaints, etc). And over time you may get some perks only available to those who munch on this type of sandwich (protected teaching/research/admin time, interesting non-clinical jobs within the system, long-term health benefits, unique retirement vehicles, pension, etc).

Working as a partner at a true SDG: congratulations, you've been able to ditch these crap sandwiches for a delicious cheeseburger. But beware...now all the CMG goons are plotting to mug you for that burger and you're also at the beck and call of c-suite who can swat that all-beef patty out of your hands if you don't kiss every patient on their way out of the ER. But then again, who cares? You have the tastiest treat in the neighborhood.

Great post. Truth + humor. It doesn't get any better than that.

 

[emergentmd]

I interviewed with Kaiser once upon a time and was shocked by how well-resourced the place was. These guys had lots of toys, could get an MRI done 24/7 within 2-3hrs, and there was a hospitalist basically sitting there waiting to admit patients.

I recall them talking about the handcuffs, but I forget--how many years do you need to stay before you're eligible for their pension?


Working at a cush freestanding (and perhaps one you own): Minimal brown stuff, and the bread is actually a delicious croissant. Most of the time it works out pretty well for ya. But the flip-side is that this pastry is delicate and may have minimal reserve to withstand stressors. It may randomly flake out and crumble away, leaving you hanging out to dry.

Pretty funny stuff. But a FSER is more like that raw dough you start with. If you are lucky, fortunate, business savvy, can control revenue cycle, and open in a decent spot then you can turn it into the best pastry an EM doc will ever taste. You get to do what you dreamed of when you went into residency. You get to have a great income seeing 1pph/hr, uncomplicated pts who typically are appreciative and care about their health, can get rid of all the uncontrollable hospital factors that impede pt care because you control all decision making, throw out all the ACA metrics/Press Ganey crap, and actually only need to worry about patient care in an efficient manner.

But you never know what will happen tomorrow if the greedy BCBS will poison your revenue cycle.

 

[GeneralVeers]

Pretty funny stuff. But a FSER is more like that raw dough you start with. If you are lucky, fortunate, business savvy, can control revenue cycle, and open in a decent spot then you can turn it into the best pastry an EM doc will ever taste. You get to do what you dreamed of when you went into residency. You get to have a great income seeing 1pph/hr, uncomplicated pts who typically are appreciative and care about their health, can get rid of all the uncontrollable hospital factors that impede pt care because you control all decision making, throw out all the ACA metrics/Press Ganey crap, and actually only need to worry about patient care in an efficient manner.

But you never know what will happen tomorrow if the greedy BCBS will poison your revenue cycle.

Sadly in many states (like mine) the tastiest bread is prohibited by state law.

 

[EctopicFetus]

Other issue is that any group of reasonable size is going to start looking like a CMG as it expands. Dealing with a hospital system is a full time job, and once the person at the top isn’t working appreciable shifts in the ED then their interests start diverging from the pit doc.

Very true. This is the issue I see with vituity who is likely the fairest of the non SDGs. The other issue is it is hard to have a reason to expand as there is often no financial win there And possibly a loss of culture.

 

[EctopicFetus]

With regards to practice of EM its easy to understand why there are different likes as we all are different. My first non CMG job was paid straight hourly. The docs hated to work, hated to see patients and as patients were assigned by the charge nurse lots of whining about patient placement. Now I’m in an RVU practice and it works well. Patients are picked up quickly but it isnt perfect it works for me though.