Why are we not discussing this? CMGs gobbling up SDGs

[EctopicFetus]

Over the past few years this has really exploded. Nothing will alter the practice environment more than this change over the next few years.

USACS, TeamHealth and EmCare (envision) has been gobbling up groups.

While not a SDG USACS just bought EPS (Texas group).

https://www.usacs.com/emergency-service-partners-joins-us-acute-care-solutions

Curious peoples thoughts?

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[da8s0859q]

I'm part of an SDG. It was/is my first job after residency.

My gut feeling – and I will defer to those with much more experience than I have, or who have been on both sides of the fence – is that there are definite rewards to this over CMGs if you are willing to put in the time and, to some degree, sweat equity (in my case as a pre-partner, so to speak).

And that's not to mention the usual benefits of a small group versus big corporate.

 

[bravotwozero]

I think this has come up in several threads from time to time. Economies of scale allowing CMGs to win over contracts, not good. Only solution I can think of is freestanding EDs (temporary) and working w2 status and unionizing.


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[GeneralVeers]

Over the past few years this has really exploded. Nothing will alter the practice environment more than this change over the next few years.

USACS, TeamHealth and EmCare (envision) has been gobbling up groups.

While not a SDG USACS just bought EPS (Texas group).

https://www.usacs.com/emergency-service-partners-joins-us-acute-care-solutions

Curious peoples thoughts?

I work for ESP. They are known to be miserly with salary/bonuses. They pale in comparison to EMP/USACS. I will not work for USACS(formerly EMP) who in my opinion was one of the worst offenders for new abusing new grads, and generally paying doctors ****ty salaries. They were failing as a company when the lost several huge contracts, so had to re-organize under the USACS banner with an infusion of a huge amount of venture capital that they've been using to outright buy other groups.

 

[emergentmd]

I work for ESP. They are known to be miserly with salary/bonuses. They pale in comparison to EMP/USACS. I will not work for USACS(formerly EMP) who in my opinion was one of the worst offenders for new abusing new grads, and generally paying doctors ****ty salaries. They were failing as a company when the lost several huge contracts, so had to re-organize under the USACS banner with an infusion of a huge amount of venture capital that they've been using to outright buy other groups.

I know ESP well, know the two overlords, know many docs who work for them, maybe even know you. Why would anyone want to stick with ESP when there are so many better options available. Its not like their work environment was anything special.

I have heard horror stories from docs who were essentially indentured servants working in the boonies at sub FSED pay with the "promise" of working in Austin that never materialized. I hope the "partners" got a decent buyout b/c I know many were good people.

I hate to see SDGs bought out but ESP needed to become extinct and they were not even a SDG to begin with.

 

[deleted109597]

Yeah, I know a ton of ESP workers. I'm not sure how to feel about this.

 

[The White Coat Investor]

The crappy thing is what SDGs are having to do to keep from getting eaten. This affects all of us, even if we're still in an SDG.

 

[Renaissance Man]

What can be done about it though?

 

[The White Coat Investor]

The best thing would be to outlaw the corporate practice of medicine.

Beyond that, SDGs need to band together with other SDGs to get the economies of scale they need to fend off the incursions.

And of course if enough doctors refused to work for them, they'd go out of business (or at least we'd all get paid more to do so, which would again hep push them out of business.)

 

[OccupyTheED]

I'm a fairly new grad, 5 months out. My first job was with a CMG. After being shafted on my first check, I immediately put in my notice. I'll probably never work (full time) for one again. It was eye-opening. I think they count on docs having a poor business sense or just taking whatever they decide to dish out. Seeing just about 2 pph and got paid $192 hourly for my last check. In the southeast at that. Like I said, never again. I now work for a SDG, if this doesn't pan out the way I'd like then I'm going the route of all locums/cold-calling medical directors.

 

[emergentmd]

ESP was a mini CMG. don't mistake this. Not all partners were equal. I didn't know their CEO was a nurse..... are you kidding me?

I will be going full fledge locums soon and will make 450K working 80hrs/mo. No more schedule requests, no more scheduled nights, no more scheduled holidays. Sure I will be working nights and holidays but it will be at my terms.

CMGs can take advantage of my brothers, But it will not be me.

 

[AlmostAnMD]

TeamHealth in central Ohio, apparently, pays so poorly they're starting to have some trouble filling positions. They might jack their base pay up from $150/hr.

But still without a partnership track or 401K matching it's still a bad decision.

 

[TooMuchResearch]

TeamHealth in central Ohio, apparently, pays so poorly they're starting to have some trouble filling positions. They might jack their base pay up from $150/hr.

But still without a partnership track or 401K matching it's still a bad decision.

But you get to live in central Ohio!

 

[swamprat]

Idk on the other hand I hear from my attendings of a lot of SDGs screwing over new grads with sweat equity and then selling out to a CMG as a retirement option for the senior partners. Happened to one guy I know, he sued and settled out of court (they knew they were selling out when they hired him so essentially they hired him under false pretenses).

 

[Everglide]

Why do you say abusing new grads? Just wondering as they seem to be ok in a non abusive way... The pay is terrible though even with their 401k and benefits

I work for ESP. They are known to be miserly with salary/bonuses. They pale in comparison to EMP/USACS. I will not work for USACS(formerly EMP) who in my opinion was one of the worst offenders for new abusing new grads, and generally paying doctors ****ty salaries. They were failing as a company when the lost several huge contracts, so had to re-organize under the USACS banner with an infusion of a huge amount of venture capital that they've been using to outright buy other groups.

 

[discongruent]

I'm a fairly new grad, 5 months out. My first job was with a CMG. After being shafted on my first check, I immediately put in my notice. I'll probably never work (full time) for one again. It was eye-opening. I think they count on docs having a poor business sense or just taking whatever they decide to dish out. Seeing just about 2 pph and got paid $192 hourly for my last check. In the southeast at that. Like I said, never again. I now work for a SDG, if this doesn't pan out the way I'd like then I'm going the route of all locums/cold-calling medical directors.

How does a new grad/almost a new grad, ensure they don't get taken for a ride on their first job?
Thought the new grad abuse wasn't so bad in EM, but more in surg/outpt fields where old fat cats feed on their young.
Isn't 192$ @ 2pph a good rate? Seems like the standard for SE US is about that.

 

[Birdstrike]

Beyond that, SDGs need to band together with other SDGs to get the economies of scale they need to fend off the incursions.

...and when this happens, you end up with something so large, it's no longer a SDG. It's something that looks an awful lot like a CMG.

 

[Birdstrike]

Either,

1-Move to Texas and get in on a FSED, or

2-Look hard for a good SDG and pray it doesn't get gobbled up by a CMG, or

3-Work Locums, enjoy the independence and suck up the instability, or

4-Work for a CMG and somehow claw your way to the top (not sure how feasible this is, nowadays), or

5-Work for a CMG and suck up the faithful soldier role & lack of control and autonomy, or

6-Get out of the ED.

 

[goodoldalky]

How does a new grad/almost a new grad, ensure they don't get taken for a ride on their first job?
Thought the new grad abuse wasn't so bad in EM, but more in surg/outpt fields where old fat cats feed on their young.
Isn't 192$ @ 2pph a good rate? Seems like the standard for SE US is about that.

The way you figure this out is go to on a bunch of real job interviews, look at a bunch of real contracts, and look at a bunch of real numbers. Break down how many hours you're working, how much the benefits are worth (i.e.: how much would it cost you to buy them if there were no benefits), how many patients you see, and you'll figure it out. It becomes quickly apparent what is a good rate and what is not. One job I interviewed for (SDG) they bragged about how the new grads make $400k.. dig, dig, dig, and come to find out, it's only their top two RVU earners who broke 400k and they both averaged 180 hours a month. Turns out that was 185 an hour and about 80 dollars an hour less than I could get somewhere else, and overall a really ****ty rate, my .02. 400k sounded good. The devil is in the details. I would not consider 192 for 2pph to be acceptable, personally.

 

[goodoldalky]

Thought the new grad abuse wasn't so bad in EM, but more in surg/outpt fields where old fat cats feed on their young.

I should address this also. There are no shortage of groups both SDG and CMG that will take you and any other doc new or old for a ride. You think they pay for a million dollar party at ACEP, SAEM, etc., out of the CEOs check? lol no. That comes right out of your check. The only way to figure it out is to do what I said above.

 

[OccupyTheED]

I sure don't consider $192 acceptable, especially when your contract's language states otherwise. Too much liability and too much time and training invested to not get paid what our skill set is worth. Not when some executive is driving a lamborghini, living in a mansion and wooing new docs with false promises off the dollars my hard work has generated. As a resident just one year ago I was so impressed with all the parties and recruitment efforts. Now I'm disgusted because I see how the dollars are really getting distributed.

 

[tsbqb]

I know ESP well, know the two overlords, know many docs who work for them, maybe even know you. Why would anyone want to stick with ESP when there are so many better options available. Its not like their work environment was anything special.

I have heard horror stories from docs who were essentially indentured servants working in the boonies at sub FSED pay with the "promise" of working in Austin that never materialized. I hope the "partners" got a decent buyout b/c I know many were good people.

I hate to see SDGs bought out but ESP needed to become extinct and they were not even a SDG to begin with.

Can you tell me anything more you know about ESP? I recently interviewed with them and walked away with a decent impression. Any info is appreciated

 

[emergentmd]

Can you tell me anything more you know about ESP? I recently interviewed with them and walked away with a decent impression. Any info is appreciated

Pm me your offer and promises. I rather not do this in a public forum.

 

[emergentmd]

The way you figure this out is go to on a bunch of real job interviews, look at a bunch of real contracts, and look at a bunch of real numbers. Break down how many hours you're working, how much the benefits are worth (i.e.: how much would it cost you to buy them if there were no benefits), how many patients you see, and you'll figure it out. It becomes quickly apparent what is a good rate and what is not. One job I interviewed for (SDG) they bragged about how the new grads make $400k.. dig, dig, dig, and come to find out, it's only their top two RVU earners who broke 400k and they both averaged 180 hours a month. Turns out that was 185 an hour and about 80 dollars an hour less than I could get somewhere else, and overall a really ****ty rate, my .02. 400k sounded good. The devil is in the details. I would not consider 192 for 2pph to be acceptable, personally.

I had a friend 10 yrs ago leave our group b/c some group in Arizona was offering such a sweet gig, 400+K, promises, promises......

She was back with our group in less than a year and just shaking her head. 400K means nothing. Ask them what that doc had to do for 400K. The most imp number is the RATE.

 

[emergentmd]

1-Move to Texas and get in on a FSED, - DOING

2-Look hard for a good SDG and pray it doesn't get gobbled up by a CMG, or - DID this, fair group, Oppss gobbled up.

3-Work Locums, enjoy the independence and suck up the instability, or - DOING, instability is overrated. There is way too many jobs avail right now that I can work 30 dys a month.

4-Work for a CMG and somehow claw your way to the top (not sure how feasible this is, nowadays), or GOOD LUCK SELLING YOUR SOUL

5-Work for a CMG and suck up the faithful soldier role & lack of control and autonomy, or DID, NEVER AGAIN

6-Get out of the ED. NAH..... GREAT FIELD, TOO MANY OPPORTUNITIES>

 

[TooMuchResearch]

I had a friend 10 yrs ago leave our group b/c some group in Arizona was offering such a sweet gig, 400+K, promises, promises......

She was back with our group in less than a year and just shaking her head. 400K means nothing. Ask them what that doc had to do for 400K. The most imp number is the RATE.

I have a buddy thinking about taking a job where "they all make $500k," which sounds great until the details of the $500k come out. They thin staff, see 3+ pph, routinely chart for 2 hours post shift, and don't use scribes, and work more hours than most. I told him to avoid the job.

 

[shoal007]

the last option is work directly for the hospital. although not as good as SDG, at least there is less overhead and usually good benefits. my total compensation is about $280/hr and i see 1.8pph with a scribe.

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[Birdstrike]

6-Get out of the ED. NAH..... GREAT FIELD, TOO MANY OPPORTUNITIES>

You're going to do this eventually. You don't plan on working in an ED until you die, do you?

 

[bikERdoc]

This thread bums me out. My goal was to get out of residency and stick with an sdg throughout my career. A year into it, I got the call from our president that they were selling out. I get it, wasn't surprised, knew it was coming. Crap part of it, is that I am still making below 50th percentile in our specialty with the promise of making partner at some point. The idea of being a partner in a cmg is so far fetched, I don't know how these guys sleep at night. Would move on if it weren't for the fact that I love my job and Co workers. And my SO loves her job as well, making us a bit too tied down for the moment...

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[discongruent]

So what this thread is suggesting all new grads still in the pipeline to attending-hood should be packing their bags and moving to TX and "getting on FSED", working locums or joining unicorn SDGs. Kind of unrealistic for thousands graduating in the next few years, and shortsighted for a 20-30 year career span.

With EM ship slowly folding upon itself, makes you wonder why still the increasing competitiveness and popularity (new programs open every year) with med students these days, especially those who are competitive for other options.

 

[VA Hopeful Dr]

So what this thread is suggesting all new grads still in the pipeline to attending-hood should be packing their bags and moving to TX and "getting on FSED", working locums or joining unicorn SDGs. Kind of unrealistic for thousands graduating in the next few years, and shortsighted for a 20-30 year career span.

With EM ship slowly folding upon itself, makes you wonder why still the increasing competitiveness and popularity (new programs open every year) with med students these days, especially those who are competitive for other options.

Well that's easy enough - even some of the lower pay that gets complained about is a good bit more than the other 3-year residency docs out there. Shift work is becoming more and more appealing. Y'all generally work fewer days than the rest of us as well. Y'all actually save lives on a fairly regular basis.

Note: please don't think I'm making light of the high stress, overnight/holiday scheduling nightmare, or any of the other downsides to EM - just that there are still many upsides that don't require moving to Texas...

 

[TooMuchResearch]

the last option is work directly for the hospital. although not as good as SDG, at least there is less overhead and usually good benefits. my total compensation is about $280/hr and i see 1.8pph with a scribe.

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That's true. There are good hospital group jobs in my area.

 

[EctopicFetus]

Good discourse. Strong advice here. Moonlight for the CMGs and make money. I get calls from recruiters all the time. I tell them simply, I wont leave my house for under $300/hr. If the job is busy the number just goes up. Thats the foot in the door money. Once I get access to all their "needs" the rate goes up closer to $400+. This residents and new attendings is how you play the game. Had a buddy make close to 1k/hr over thanksgiving. It is out there. Do not settle for $250/hr. The CMGs have great contracts with payers they make a lot of money. I make them put it in my pocket or I wont work.

 

[emergentmd]

Locums is not for everyone esp when they have family. But doing some is great but have a stable gig b/c if they are not desperate, you might not work a shift that month. No big deal.

I worked 200 hrs locums last year and cleared 100K.

 

[Brahnold Bloodaxe]

CMGs buying up SDGs is the first phase. The second phase will consist of CMG mergers leading to total regional market dominance by one or two groups.

I think you all know what happens to wages under a monopsony.

 

[GeneralVeers]

CMGs buying up SDGs is the first phase. The second phase will consist of CMG mergers leading to total regional market dominance by one or two groups.

I think you all know what happens to wages under a monopsony.

I don't think wages will change much until supply of physicians equal demand. My home market is dominated by EmCare and TeamHealth with no SDGs. They simply cannot get enough docs to work for them despite paying $300+/hour.

 

[justaregularmed]

I find it so fascinating that the hourly rates quoted in this thread are higher then the total compensation of any job i've heard about in my area (and granted I don't know everything). Regional variation is a very curious thing. I never critically looked at the medscape region map, its pretty crazy.

 

[GeneralVeers]

I find it so fascinating that the hourly rates quoted in this thread are higher then the total compensation of any job i've heard about in my area (and granted I don't know everything). Regional variation is a very curious thing. I never critically looked at the medscape region map, its pretty crazy.

It has to do with supply and demand. "Cool" metro areas like San Diego, San Francisco, Austin, New York and Denver pay a lot less because the groups do not have to pay as much to attract and retain people.

 

[DaTruMD]

ESP was a mini CMG. don't mistake this. Not all partners were equal. I didn't know their CEO was a nurse..... are you kidding me?

I will be going full fledge locums soon and will make 450K working 80hrs/mo. No more schedule requests, no more scheduled nights, no more scheduled holidays. Sure I will be working nights and holidays but it will be at my terms.

CMGs can take advantage of my brothers, But it will not be me.

Wow. EM sounds like a really sweet gig right now.

 

[DaTruMD]

Hey guys, med student applying to IM right now. Was wondering why there is such a discrepancy in hourly wage between EM docs and hospitalists. Is it mainly a supply issue?

 

[deleted109597]

Hey guys, med student applying to IM right now. Was wondering why there is such a discrepancy in hourly wage between EM docs and hospitalists. Is it mainly a supply issue?

It's billing. The average ED doc sees 20 or more patients in 8 or more hours. They admit 10-20%. The hospitalist then gets 10-20% of those. That's 2-5 patients.
I've known plenty of hospitalists who clear >$300k though.

 

[goodoldalky]

Hey guys, med student applying to IM right now. Was wondering why there is such a discrepancy in hourly wage between EM docs and hospitalists. Is it mainly a supply issue?

Hospitalists do fairly well. Most of the higher EM rates quoted are such because of two reasons: 1. Pay for productivity, which sometimes pushes docs to clear 3+pph and document/bill well and 2. The number of highly reimbursed procedures is much higher than a hospitalist typically does. At my shop hospitalists call consultant or resident teams to do their procedures.

 

[Alvarez13]

I've signed on with a midwest SDG and will start July. Like the people and nice big city, 135 hrs/mo. With all the benefits (CME, disability, health, etc) and everything combined it's $235/hr year 1, $265/hr year 2, and $285/hr year 3 when you're a full partner. The hourly is like $140 but when you add the bonus and 401k it's like $210/hr for the new guys and then the bonus ramps up. I thought this was pretty good, but you guys are making me feel self conscious. I've worked so hard this last year, just don't want to get screwed.

 

[bravotwozero]

Make sure you sign up for a locums gig/prn shifts at another ed as backup


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[emergentmd]

I've signed on with a midwest SDG and will start July. Like the people and nice big city, 135 hrs/mo. With all the benefits (CME, disability, health, etc) and everything combined it's $235/hr year 1, $265/hr year 2, and $285/hr year 3 when you're a full partner. The hourly is like $140 but when you add the bonus and 401k it's like $210/hr for the new guys and then the bonus ramps up. I thought this was pretty good, but you guys are making me feel self conscious. I've worked so hard this last year, just don't want to get screwed.

These are good numbers in a good group. If you are full partner = full equity and ownership then I think its a really Good/Great deal. If it doesn't come with equity, then you are really not an owner with very little say.

 

[Siggy]

Hey guys, med student applying to IM right now. Was wondering why there is such a discrepancy in hourly wage between EM docs and hospitalists. Is it mainly a supply issue?

Hospitalist work, pay wise, is a lot like EM, just a little lower. The places where everyone wants to live can absolutely suck (South Florida tends to be low to mid-200k with hospitalists seeing 25-30 patients/day). On the other hand, the 3rd years are getting offers to staff critical access hospitals in BFE for 300k+ for 1 week on (24/7), 3 weeks off.

 

[uhhhh]

I find it so fascinating that the hourly rates quoted in this thread are higher then the total compensation of any job i've heard about in my area (and granted I don't know everything). Regional variation is a very curious thing. I never critically looked at the medscape region map, its pretty crazy.

http://www.acepnow.com/article/emer...-report-shows-lack-standardization-specialty/

 

[deleted109597]

I've signed on with a midwest SDG and will start July. Like the people and nice big city, 135 hrs/mo. With all the benefits (CME, disability, health, etc) and everything combined it's $235/hr year 1, $265/hr year 2, and $285/hr year 3 when you're a full partner. The hourly is like $140 but when you add the bonus and 401k it's like $210/hr for the new guys and then the bonus ramps up. I thought this was pretty good, but you guys are making me feel self conscious. I've worked so hard this last year, just don't want to get screwed.

I would love to see a benefits package that ends up at $100/hr.
$210/hr is nothing to shake a stick at. If you like the city, you'll be fine as long as the cost of living is ok.

 

[DissocativFugue]

http://www.acepnow.com/article/emer...-report-shows-lack-standardization-specialty/

I was blown away at this statement, "Within the next five years, emergency physicians living and working in New York may require food stamps to make ends meet if incomes aren’t adjusted to the cost of living!"


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[emergentmd]

Pay in NYC is a joke. So is Hawaii.

Got a call from a recruiter who knows not to call me unless its north of $300/hr. He said he had a HOT lead in Hawaii that he wanted to talk about. I know the going rate in Hawaii and when he told me it was $200/hr, I didn't even let him finish his statement.

Sad but $200/hr is super high for Hawaii, but I rather visit on vacation for a month than live there for $200/hr