why does EM make so much money?

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There is no argument to be had; general surgeons work far more hours than em doctors.
 
They probably won't soon. Basically, EM physicians could bill what was deemed "reasonable" in the past, but that has been struck down, and now insurers can pay them whatever low amount they choose to, while EM physicians are forced to see any and all patients under the EMTLA. What this amounts to is you're forced to work for whatever wages the government or private insurers decide to pay you, even if it is less than your services are worth. And since you can't turn their patients away, you have no bargaining power. My bet is salaries are going to decline 30% or more in the coming years.

As to why they were paid that much, the reasonable rate clause meant they charged everyone whatever they deemed reasonable. 95% of patients in the ED should have gone to a PCP for a $75 visit, but instead they've gone to the ED, which charges the reasonable rate for an emergency, typically around $750-2,000, even for a primary care level of complaint. So often you're billing 5-10 times what a PCP would for the same care, which obviously adds up to piles of cash. Now that the reasonable rate clause has been rescinded, it is likely ED physicians will be paid urgent care rates for primary care level services, which are about a third of what they currently bill.
 
Mad Jack said:
They probably won't soon. Basically, EM physicians could bill what was deemed "reasonable" in the past, but that has been struck down, and now insurers can pay them whatever low amount they choose to, while EM physicians are forced to see any and all patients under the EMTLA. What this amounts to is you're forced to work for whatever wages the government or private insurers decide to pay you, even if it is less than your services are worth. And since you can't turn their patients away, you have no bargaining power. My bet is salaries are going to decline 30% or more in the coming years.

As to why they were paid that much, the reasonable rate clause meant they charged everyone whatever they deemed reasonable. 95% of patients in the ED should have gone to a PCP for a $75 visit, but instead they've gone to the ED, which charges the reasonable rate for an emergency, typically around $750-2,000, even for a primary care level of complaint. So often you're billing 5-10 times what a PCP would for the same care, which obviously adds up to piles of cash. Now that the reasonable rate clause has been rescinded, it is likely ED physicians will be paid urgent care rates for primary care level services, which are about a third of what they currently bill.
Click to expand...
I think that would be the end of EMs attractiveness as a specialty. The hospital I work at (overflow for the main/trauma hospital in my area) we will get 4-5 legitimately sick patients (aka: those who should actually be in the ER) in the span of a 16 hour shift... easily overshadowed by the 40 others who don't have jack s**t wrong with them.

I love working in the ER, and I love when something real comes in, but the stuff that is not real is soul sucking and slowly eats away at you.
 
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frosted_flake said:
I think that would be the end of EMs attractiveness as a specialty. The hospital I work at (overflow for the main/trauma hospital in my area) we will get 4-5 legitimately sick patients (aka: those who should actually be in the ER) in the span of a 16 hour shift... easily overshadowed by the 40 others who don't have jack s**t wrong with them.
Click to expand...
Yeah- it's not every day that you see something that looks like it's going to devastate a specialty, but this is certainly one of those things, much as molecular and non-microscopic techniques caused a massive destruction of the reimbursement for pathology and left the specialty in ruins. We'll see how things go, but with this new law, the only way reimbursements can go is down, down, down.
 
frosted_flake said:
I think that would be the end of EMs attractiveness as a specialty. The hospital I work at (overflow for the main/trauma hospital in my area) we will get 4-5 legitimately sick patients (aka: those who should actually be in the ER) in the span of a 16 hour shift... easily overshadowed by the 40 others who don't have jack s**t wrong with them.
Click to expand...

Agreed on a typical 9 hour night shift at a L1 trauma center we might get a fall w/ possible closed head injury/teenie laceration on thinners, 2-3 copd exacerbations, 2-3 sepsis workups, 17 babies with rhinorrhea-uri like sx/otitis media (all w/ a fever less than 102.5), 5-6 drug abusers, a few croupers, 10 gi like sx w/ maybe 2 ending up as productive workups, and every now and then a decent trauma. I am very happy to have scribed before pursuing medical school. I had a very different idea of what EM was prior to spending a year+ in the setting. Grateful for the experience however. You get broad exposure to a large amount of presentations which has been tremendously helpful. A lot of the EP's I worked for complained when they worked an hour over 130 a month. (thats 42.5 hours a week at 280-320k starting compared to your general surgeon who works a solid 70-80 and gets paid at the same level in a major city.
 
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plukfelder2017 said:
Agreed on a typical 9 hour night shift at a L1 trauma center we might get a fall w/ possible closed head injury/teenie laceration on thinners, 2-3 copd exacerbations, 2-3 sepsis workups, 17 babies with rhinorrhea-uri like sx/otitis media (all w/ a fever less than 102.5), 5-6 drug abusers, a few croupers, 10 gi like sx w/ maybe 2 ending up as productive workups, and every now and then a decent trauma. I am very happy to have scribed before moving into medical school. I had a very different idea of what EM was prior to spending a year in the setting.
Click to expand...

Absolutely! My work experience (EMS/ER tech) has made me appreciate when ER docs do when s**t hits the fan, but I do not envy their job on the whole. I talk to the scribes I work with and they feel the same way (as do the nurses, doctors, etc.) we all love it, but it breaks you. I have learned we are one hell of a family though! Nothing like the dynamic of working in the ER, especially those you get along with.

/sorry for the hijack :hijacked:
 
plukfelder2017 said:
Agreed on a typical 9 hour night shift at a L1 trauma center we might get a fall w/ possible closed head injury/teenie laceration on thinners, 2-3 copd exacerbations, 2-3 sepsis workups, 17 babies with rhinorrhea-uri like sx/otitis media (all w/ a fever less than 102.5), 5-6 drug abusers, a few croupers, 10 gi like sx w/ maybe 2 ending up as productive workups, and every now and then a decent trauma. I am very happy to have scribed before pursuing medical school. I had a very different idea of what EM was prior to spending a year+ in the setting. Grateful for the experience however. You get broad exposure to a large amount of presentations which has been tremendously helpful. A lot of the EP's I worked for complained when they worked an hour over 130 a month. (thats 42.5 hours a week at 280-320k starting compared to your general surgeon who works a solid 70-80 and gets paid at the same level in a major city.
Click to expand...
Actually, at 130 hours a month comes to just over 32 hours a week at 48 weeks of work per year.

(130*12)/48
 
Mad Jack said:
Actually, at 130 hours a month comes to just over 32 hours a week at 48 weeks of work per year.

(130*12)/48
Click to expand...
Ah whoops thats just ****ty math on my behalf. I still found it hilarious, when I heard them complaining about the amount of hours they worked in the physician group. I moved over from i-banking to medicine and used to work 80-100 hours a week but was compensated at a commensurate level. It doesn't seem like their compensation is commensurate with the actual work that they perform, not including the administrative garbage that they have to deal with. I have seen very few EPs actually take the proactive effort to workup a trauma patient in the ED prior to calling the surgeon. As soon as they have a flight for life or EMS alert on a trauma, they go in evaluate the patient for a second and say "my work here is done, call the trauma surgeon." My personal stance is as follows, up physician compensation in the surgical fields where the risk is greater/ the impact is immediate, and reduce physician compensation in others while hiring more mid-levels to staff EDs in the night and clear excess flow (colds, coughs, OM, simple lacs). Sure fast tracks are present but are they ever effectively staffed? Maybe my hospital was n=1, but I didn't have that experience.
 
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Mad Jack said:
They probably won't soon. Basically, EM physicians could bill what was deemed "reasonable" in the past, but that has been struck down, and now insurers can pay them whatever low amount they choose to, while EM physicians are forced to see any and all patients under the EMTLA. What this amounts to is you're forced to work for whatever wages the government or private insurers decide to pay you, even if it is less than your services are worth. And since you can't turn their patients away, you have no bargaining power. My bet is salaries are going to decline 30% or more in the coming years.

As to why they were paid that much, the reasonable rate clause meant they charged everyone whatever they deemed reasonable. 95% of patients in the ED should have gone to a PCP for a $75 visit, but instead they've gone to the ED, which charges the reasonable rate for an emergency, typically around $750-2,000, even for a primary care level of complaint. So often you're billing 5-10 times what a PCP would for the same care, which obviously adds up to piles of cash. Now that the reasonable rate clause has been rescinded, it is likely ED physicians will be paid urgent care rates for primary care level services, which are about a third of what they currently bill.
Click to expand...


First of all, you need to understand how ER doctors get paid.

ER is universally a group specialty. They work in private groups, and the group gets a contract for coverage at the local ED. Most pay their doctors one of three ways

1. straight hourly
2. straight RVU (how much you personally billed for)
3. Combination of both

Additionally members of the group may also become partner and share in the total take from that group, but that is beyond this discussion

The ED group is hired to solve a single problem, and that is that people keep showing up at the hospital. It used to be that all doctors who had hospital rights had to put their time in at the ED. Pediatricians, surgeons, everyone. Soon ED developed as its own specialty that focused on the immediate identification and treatment of life-threatening illness. We have many unique skills. All the other doctors were free to just do what they wanted to do, and not have to put 2 days a month in at the ED.

The ER is critical to a hospital, because that is where admissions come from. Direct admit from a doctor's office is rare, most PCP's just send them to the ED. To get admission, you need an exam and diagnosis from a physician that demonstrates they meet criteria for inpatient admission. We get paid because we provide that, and we take on the liability for everyone we discharge. That is why we are so valuable. Most ED's have a 20-30% admission rate, so it really isn't as much nonsense as you think.

Not all ED visits are the same, nor are they coded for and billed the same way. There are different levels of management, and procedures and radiology are billed for differently, but you need to have a physician who can verify that their problem warrants labs or an XRay, No physician, no order, no billing. The more complex the case, the more resources it uses, the higher it bills for.

To deal with the hordes of non-emergent ED visits, most departments develop a fast track so quickly shunt those people to a different area, have them seen by a PA, and then quickly discharged with a script for their UTI. The reimbursement is low, but so is the allocation of resources. Those simple cases never got paid $1000, they get paid like $80, which is nothing new.

EMTALA isn't new. Balanced billing isn't new. Nothing about this is new. EM physician compensation has increased steadily since the passage of the ACA, and the field is looking great for the future.
 
frosted_flake said:
I think that would be the end of EMs attractiveness as a specialty. The hospital I work at (overflow for the main/trauma hospital in my area) we will get 4-5 legitimately sick patients (aka: those who should actually be in the ER) in the span of a 16 hour shift... easily overshadowed by the 40 others who don't have jack s**t wrong with them.

I love working in the ER, and I love when something real comes in, but the stuff that is not real is soul sucking and slowly eats away at you.
Click to expand...


It is a very in demand field. I am still a resident, and I barely go a week without getting called or emailed for moonlighting coverage at rural shops. Money is good, flexible hours, and the applications from med students reach the ceiling every year.
 
HooliganSnail said:
First of all, you need to understand how ER doctors get paid.

ER is universally a group specialty. They work in private groups, and the group gets a contract for coverage at the local ED. Most pay their doctors one of three ways

1. straight hourly
2. straight RVU (how much you personally billed for)
3. Combination of both

Additionally members of the group may also become partner and share in the total take from that group, but that is beyond this discussion

The ED group is hired to solve a single problem, and that is that people keep showing up at the hospital. It used to be that all doctors who had hospital rights had to put their time in at the ED. Pediatricians, surgeons, everyone. Soon ED developed as its own specialty that focused on the immediate identification and treatment of life-threatening illness. We have many unique skills. All the other doctors were free to just do what they wanted to do, and not have to put 2 days a month in at the ED.

The ER is critical to a hospital, because that is where admissions come from. Direct admit from a doctor's office is rare, most PCP's just send them to the ED. To get admission, you need an exam and diagnosis from a physician that demonstrates they meet criteria for inpatient admission. We get paid because we provide that, and we take on the liability for everyone we discharge. That is why we are so valuable. Most ED's have a 20-30% admission rate, so it really isn't as much nonsense as you think.

Not all ED visits are the same, nor are they coded for and billed the same way. There are different levels of management, and procedures and radiology are billed for differently, but you need to have a physician who can verify that their problem warrants labs or an XRay, No physician, no order, no billing. The more complex the case, the more resources it uses, the higher it bills for.

To deal with the hordes of non-emergent ED visits, most departments develop a fast track so quickly shunt those people to a different area, have them seen by a PA, and then quickly discharged with a script for their UTI. The reimbursement is low, but so is the allocation of resources. Those simple cases never got paid $1000, they get paid like $80, which is nothing new.

EMTALA isn't new. Balanced billing isn't new. Nothing about this is new. EM physician compensation has increased steadily since the passage of the ACA, and the field is looking great for the future.
Click to expand...
But a lot of states are banning balance billing, and there is also legislation in some states that is requiring uniformity of insurance acceptance by physicians within a facility (basically, if the facility is in-network, all physicians must accept in-network rates) that is looking to be passed. While EDs are critical to a hospital, if they aren't making as much as they used to, they'll do the same thing they did with anesthesia- look to replace providers and pay less, since the ED has become a net loss in regard to hospital income and the suits up top will do their best to minimize that loss.

I mean, this is all hypothetical, but I see the reimbursement climate getting substantially worse for EM over the next decade.
 
HooliganSnail said:
It is a very in demand field. I am still a resident, and I barely go a week without getting called or emailed for moonlighting coverage at rural shops. Money is good, flexible hours, and the applications from med students reach the ceiling every year.
Click to expand...
Do you mind me asking if you work in an urban or rural area? I think there would be pros and cons of either.
Stabbings, GSWs, traumas in the city versus farm accidents, lack of access to (close and appropriate) care, etc on the rural side.

What specifically drew you to EM?

Your username is hilarious by the way :laugh:
 
frosted_flake said:
Do you mind me asking if you work in an urban or rural area? I think there would be pros and cons of either.
Stabbings, GSWs, traumas in the city versus farm accidents, lack of access to (close and appropriate) care, etc on the rural side.

What specifically drew you to EM?

Your username is hilarious by the way :laugh:
Click to expand...


Currently I work in a community urban ER. We are in a smaller urban area outside a major city, next to a few major highways. We see a good mix of penetrating and blunt force trauma. We keep a lot of trauma, but we also transfer a fair amount as well. I like training in an urban area, most residencies are in an urban area. As a resident, you want to get the most experience with crazy situations so that as an attending you are comfortable with anything, but hopefully you don't have to do it.

Don't do EM at a tertiary academic center. All the other specialties will steal your thunder. Don't be fooled by the 'Level 1 Trauma", in those places the surgery and trauma team handle everything, and ER just does the airway. You want to be at a place that gets trauma, but doesn't have a large presence of other residencies.

I was drawn to EM because it is exciting. I get to do lots of cool procedures, some of which are lifesaving. I get to stick huge needles in people's necks. I like the lifestyle, I like that when I go home, no one is calling me back in about a patient. I hate being on call. I hate rounding and writing progress notes. I HATE the OR, too stuffy and hot.

ER is for me man.
 
Mad Jack said:
But a lot of states are banning balance billing, and there is also legislation in some states that is requiring uniformity of insurance acceptance by physicians within a facility (basically, if the facility is in-network, all physicians must accept in-network rates) that is looking to be passed. While EDs are critical to a hospital, if they aren't making as much as they used to, they'll do the same thing they did with anesthesia- look to replace providers and pay less, since the ED has become a net loss in regard to hospital income and the suits up top will do their best to minimize that loss.

I mean, this is all hypothetical, but I see the reimbursement climate getting substantially worse for EM over the next decade.
Click to expand...

What you are saying has merit, and there are many who are concerned about it.

For my sake, I hope your wrong. Although I intend to practice rurally when I'm finished with residency, so compensation will never be a problem for me.
 
HooliganSnail said:
It is a very in demand field. I am still a resident, and I barely go a week without getting called or emailed for moonlighting coverage at rural shops. Money is good, flexible hours, and the applications from med students reach the ceiling every year.
Click to expand...

How good is good? Im curious because I have been thinking about EM. Worked as a scribe there....... I heard the doctors are making at least $180/hour.
 
HooliganSnail said:
Currently I work in a community urban ER. We are in a smaller urban area outside a major city, next to a few major highways. We see a good mix of penetrating and blunt force trauma. We keep a lot of trauma, but we also transfer a fair amount as well. I like training in an urban area, most residencies are in an urban area. As a resident, you want to get the most experience with crazy situations so that as an attending you are comfortable with anything, but hopefully you don't have to do it.

Don't do EM at a tertiary academic center. All the other specialties will steal your thunder. Don't be fooled by the 'Level 1 Trauma", in those places the surgery and trauma team handle everything, and ER just does the airway. You want to be at a place that gets trauma, but doesn't have a large presence of other residencies.

I was drawn to EM because it is exciting. I get to do lots of cool procedures, some of which are lifesaving. I get to stick huge needles in people's necks. I like the lifestyle, I like that when I go home, no one is calling me back in about a patient. I hate being on call. I hate rounding and writing progress notes. I HATE the OR, too stuffy and hot.

ER is for me man.
Click to expand...
I have noticed that when we take patients to the trauma bay... they swarm them, and the poor little ER resident is standing in the corner to avoid being trampled by everyone else. I really enjoy hands-on work, and I thought EM would provide that, but I have come to realize the times when an intubation is required is rare (I have seen more intubations in the ambulance than the ER), and I have only seen a doc start an EJ once... and that was because the patient wanted lidocaine (and was still screaming like a child who dropped their ice cream).
In my experience shadowing, anesthesia provides many opportunities for hands-on work... intubations, IVs, pushing meds, etc. I think I would really enjoy it as a specialty, but I am definitely keeping my options open 🙂
 
oOKawaiiOo said:
How good is good? Im curious because I have been thinking about EM. Worked as a scribe there....... I heard the doctors are making at least $180/hour.
Click to expand...
I have had residents tell me $180-200 an hour.
But boy oh boy the nurses hate when the new(er) residents moonlight. They talk so badly about them 🙁 Forgetting to put in meds, orders, etc. I want to ask them if they never made a mistake when they started working solo :yeahright:
 
oOKawaiiOo said:
How good is good? Im curious because I have been thinking about EM. Worked as a scribe there....... I heard the doctors are making at least $180/hour.
Click to expand...


Correct. It varies from city to city. Manhattan not nearly that much, Hawaii......forget about it. But a lot of places make that much money.
 
frosted_flake said:
I have noticed that when we take patients to the trauma bay... they swarm them, and the poor little ER resident is standing in the corner to avoid being trampled by everyone else. I really enjoy hands-on work, and I thought EM would provide that, but I have come to realize the times when an intubation is required is rare (I have seen more intubations in the ambulance than the ER), and I have only seen a doc start an EJ once... and that was because the patient wanted lidocaine (and was still screaming like a child who dropped their ice cream).
In my experience shadowing, anesthesia provides many opportunities for hands-on work... intubations, IVs, pushing meds, etc. I think I would really enjoy it as a specialty, but I am definitely keeping my options open 🙂
Click to expand...

I'm not sure about started an IV for lidocaine......I think you mean morphine

I've intubated three people this week
 
Mad Jack said:
They probably won't soon. Basically, EM physicians could bill what was deemed "reasonable" in the past, but that has been struck down, and now insurers can pay them whatever low amount they choose to, while EM physicians are forced to see any and all patients under the EMTLA. What this amounts to is you're forced to work for whatever wages the government or private insurers decide to pay you, even if it is less than your services are worth. And since you can't turn their patients away, you have no bargaining power. My bet is salaries are going to decline 30% or more in the coming years.

As to why they were paid that much, the reasonable rate clause meant they charged everyone whatever they deemed reasonable. 95% of patients in the ED should have gone to a PCP for a $75 visit, but instead they've gone to the ED, which charges the reasonable rate for an emergency, typically around $750-2,000, even for a primary care level of complaint. So often you're billing 5-10 times what a PCP would for the same care, which obviously adds up to piles of cash. Now that the reasonable rate clause has been rescinded, it is likely ED physicians will be paid urgent care rates for primary care level services, which are about a third of what they currently bill.
Click to expand...

Could you point me to a source on this? I totally believe you, but I'm not an EM-buff so this is the first I've heard of it and I'd like to learn more. (I know about EMTLA but not about the reasonable rate clause).
 
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