Yet another reason to avoid private equity run emergency departments.

[alpinism]

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Members do not see this ad.

NBC News: Weiss Hospital in Chicago loses medicare funds over lack of ER services

​

Weiss hospital emergency room ‘not safe for patients,'​

ER medical director tells state​

Days before the federal government revoked Weiss Memorial Hospital’s Medicare access, state investigators found the hospital had been operating a “makeshift” emergency department in an office building that lacked the basic equipment and staff to properly care for patients, according to state records obtained by the Sun-Times.

Two doctors and a nurse interviewed by the Illinois Department of Public Health said the makeshift emergency room made it nearly impossible to treat patients because it lacked medications, oxygen supplies and monitoring equipment.

Three patients who came to the Uptown safety net hospital for treatment in late June and early July could not get the care they needed, the investigation found.

 

[AlmostAnMD]

Another take, one a bit more optimistic, is reporting these kind of things to state authorities can actually work. Nice.

 

[endo]

NBC News: Weiss Hospital in Chicago loses medicare funds over lack of ER services

​

Weiss hospital emergency room ‘not safe for patients,'​

ER medical director tells state​

Days before the federal government revoked Weiss Memorial Hospital’s Medicare access, state investigators found the hospital had been operating a “makeshift” emergency department in an office building that lacked the basic equipment and staff to properly care for patients, according to state records obtained by the Sun-Times.

Two doctors and a nurse interviewed by the Illinois Department of Public Health said the makeshift emergency room made it nearly impossible to treat patients because it lacked medications, oxygen supplies and monitoring equipment.

Three patients who came to the Uptown safety net hospital for treatment in late June and early July could not get the care they needed, the investigation found.

Did you see the CEO? Is he also running a brothel out of that place?

 

[ShockIndex]

Did you see the CEO? Is he also running a brothel out of that place?

https://www.austinweeklynews.com/wp-content/uploads/2024/11/The-People-vs-Manoj-Prasad.pdf

 

[EctopicFetus]

In other news.. i heard USUCKS has their admin leads scour the internet and report back anyone / anything bad said about he crappy company. Talk about a soul sucking job. Meanwhile their owners have no idea what is happening in that company and they owe 250k or so per doc in loans. Sounds like a horrific job. I cant figure out if Sound physicians or USACS is the crappier employer. Remember Sound took on the old APP leader as their new boss after he ran APP into the ground.

 

[WhatJobDoIPick]

In other news.. i heard USUCKS has their admin leads scour the internet and report back anyone / anything bad said about he crappy company. Talk about a soul sucking job. Meanwhile their owners have no idea what is happening in that company and they owe 250k or so per doc in loans. Sounds like a horrific job. I cant figure out if Sound physicians or USACS is the crappier employer. Remember Sound took on the old APP leader as their new boss after he ran APP into the ground.

Anyone working for a CMG in 2025 is getting exactly what they deserve. You can no longer claim ignorance.

 

[Porfirio]

Make sure you get a $50,000+ sign on bonus and save it. Just in case the CMG goes bankrupt and you have to buy medmal tail coverage.

 

[Major]

In other news.. i heard USUCKS has their admin leads scour the internet and report back anyone / anything bad said about he crappy company. Talk about a soul sucking job. Meanwhile their owners have no idea what is happening in that company and they owe 250k or so per doc in loans. Sounds like a horrific job. I cant figure out if Sound physicians or USACS is the crappier employer. Remember Sound took on the old APP leader as their new boss after he ran APP into the ground.

That is exactly what happened to me several years ago on this board. You would think they would be like “gee why do physicians hate us so much, we should really figure this out and correct course.” But nope, instead they put energy into finding out who this is message board poster is and black ball them!

 

[AlmostAnMD]

That is exactly what happened to me several years ago on this board. You would think they would be like “gee why do physicians hate us so much, we should really figure this out and correct course.” But nope, instead they put energy into finding out who this is message board poster is and black ball them!

I think it's just in human nature

the UHC assassination is a great example too

instead of anyone doing soul searching about why someone would assassinate a healthcare executive and see how people are literally cheering for the guy/sending him legal funds now in 7 figs/they just hire more private security and scrub the executive names off all the sites to prevent a second assassination.

Instead of wondering how this is happening

A lot has changed in 30 years of medicine or so. 30 years ago if someone assassinated a healthcare executive even the most radical people wouldn't be openly celebrating. Not being receptive to feedback is a dangerous feedback loop indeed.

 

[EctopicFetus]

That is exactly what happened to me several years ago on this board. You would think they would be like “gee why do physicians hate us so much, we should really figure this out and correct course.” But nope, instead they put energy into finding out who this is message board poster is and black ball them!

Yep. Their real effort is in hiding their reputation from hospitals so they can grow. In addition, what they try to do is push their stupid narrative of “our docs dont get sued”. It is so dumb and fake and pushing their stupid phone number where you can call someone. As an admitted outsider it feels like something you would do for an NP or when you know you end up hiring lower tier docs.

They work so hard to hide their warts instead of using that energy to correct their warts. eventually it will collapse. Their financial performance sucks, and they have massive debt. I believe they lost their big atrium contract and while they did pick up contracts elsewhere their business is one that mandates growth. I dont see how they will make that happen.

 

[Major]

A

Yep. Their real effort is in hiding their reputation from hospitals so they can grow. In addition, what they try to do is push their stupid narrative of “our docs dont get sued”. It is so dumb and fake and pushing their stupid phone number where you can call someone. As an admitted outsider it feels like something you would do for an NP or when you know you end up hiring lower tier docs.

They work so hard to hide their warts instead of using that energy to correct their warts. eventually it will collapse. Their financial performance sucks, and they have massive debt. I believe they lost their big atrium contract and while they did pick up contracts elsewhere their business is one that mandates growth. I dont see how they will make that happen.

I read they recently fired their ceo and replaced him with some mba

 

[BoardingDoc]

I think it's just in human nature

the UHC assassination is a great example too

instead of anyone doing soul searching about why someone would assassinate a healthcare executive and see how people are literally cheering for the guy/sending him legal funds now in 7 figs/they just hire more private security and scrub the executive names off all the sites to prevent a second assassination.

Instead of wondering how this is happening

A lot has changed in 30 years of medicine or so. 30 years ago if someone assassinated a healthcare executive even the most radical people wouldn't be openly celebrating. Not being receptive to feedback is a dangerous feedback loop indeed.

You mean they never had this moment?

 

[Apollyon]

I still can't believe a dude making $500mil/yr, in a field that's not really loved publicly, didn't have personal security. I mean, when an FM doc left the clinic that was remote from our hospital, they had armed security from all the junkies that had been cut off.

If ancient Egyptians knew you needed security, it's not a new idea.

 

[southerndoc]

I still can't believe a dude making $500mil/yr, in a field that's not really loved publicly, didn't have personal security. I mean, when an FM doc left the clinic that was remote from our hospital, they had armed security from all the junkies that had been cut off.

If ancient Egyptians knew you needed security, it's not a new idea.

I think you have too many zeroes in your amount. Base salary was $1 mil and he received $9 mil in other compensation (stock, travel, etc.).

 

[Apollyon]

I think you have too many zeroes in your amount. Base salary was $1 mil and he received $9 mil in other compensation (stock, travel, etc.).

I thought the guy was absolutely swimming in $$. My error. What's weird is, the $500 didn't even seem outrageously incorrect.

 

[EctopicFetus]

I thought the guy was absolutely swimming in $$. My error. What's weird is, the $500 didn't even seem outrageously incorrect.

To be fair this is some weird belief of people. Much of the money these guys make when they make outlandish salaries is from stock options. There are always exceptions but the actual salary of CEOs is not as crazy as people think. Found this from the AFL-CIO but note they say salary and then mention total compensation.

Highest-Paid CEOs - 2025 | AFL-CIO

aflcio.org

I mean lets say I am a ceo of a company and lets use NVIDIA as an example, I take the company from being worth under 20B B to 4.2 trillion over the last decade. I have created $4T+ in value. How much should I get? The board of directors of these companies do it with stocks, options etc to align incentives. Surely some deals are better than others but let’s say his total comp was $1b in that time (I have no idea) thats a great return for the company since he still created over $4t in returns for the owners of that company.

This is an extreme example and there is a worthy discussion of how much is enough but very few CEOs true salary is over $20m. Is that still a ton of money.. sure it is.. That being said I would bet there are more pro athletes / movie stars making over $20m a year than there are CEOs makibng that purely in salary.

FWIW at the end of this post i looked up how much the NVIDIA CEO (who was also the founder) got. Here is what google got me.

Nvidia CEO Jensen Huang's total compensation for fiscal year 2025 is approximately $50 million, according to a recent report from Yahoo Finance.This includes a base salary of $1.5 million, a target cash bonus of $3 million, and stock awards valued at $38.8 million, according to TheStreet.com and Yahoo Finance. The increase in compensation is largely due to the significant rise in Nvidia's stock value, reflecting the company's success in the AI industry

 

[Arcan57]

To be fair, $10mil is still generational wealth. It's just not Russian nesting doll made of yachts rich.

 

[Arcan57]

To be fair this is some weird belief of people. Much of the money these guys make when they make outlandish salaries is from stock options. There are always exceptions but the actual salary of CEOs is not as crazy as people think. Found this from the AFL-CIO but note they say salary and then mention total compensation.

Highest-Paid CEOs - 2025 | AFL-CIO

aflcio.org

I mean lets say I am a ceo of a company and lets use NVIDIA as an example, I take the company from being worth under 20B B to 4.2 trillion over the last decade. I have created $4T+ in value. How much should I get? The board of directors of these companies do it with stocks, options etc to align incentives. Surely some deals are better than others but let’s say his total comp was $1b in that time (I have no idea) thats a great return for the company since he still created over $4t in returns for the owners of that company.

This is an extreme example and there is a worthy discussion of how much is enough but very few CEOs true salary is over $20m. Is that still a ton of money.. sure it is.. That being said I would bet there are more pro athletes / movie stars making over $20m a year than there are CEOs makibng that purely in salary.

FWIW at the end of this post i looked up how much the NVIDIA CEO (who was also the founder) got. Here is what google got me.

Nvidia CEO Jensen Huang's total compensation for fiscal year 2025 is approximately $50 million, according to a recent report from Yahoo Finance.This includes a base salary of $1.5 million, a target cash bonus of $3 million, and stock awards valued at $38.8 million, according to TheStreet.com and Yahoo Finance. The increase in compensation is largely due to the significant rise in Nvidia's stock value, reflecting the company's success in the AI industry

That's an excellent point but given how tax advantaged wealth from stock is, doesn't that actually make their compensation even more disproportionate? A pro athlete is going to lose a significant amount of their salary to the state, while the CEO can leverage their stock in ways that cost a fraction of the taxes levied againt Ohtani, Messi, or Mahomes.

 

[bravotwozero]

Not only have they ruined EM, they've also ruined one of my favorite airlines - Southwest. Free bags, gone. Open Seating, gone. No change fees, gone. This is why we can't have nice things

 

[Porfirio]

Yes, stock options are way better than salary (especially large companies).

Startups are way more risky.

 

[Major]

Steve Jobs took only $1.00 as his salary from Apple. The rest was stock options…

 

[RustedFox]

Not only have they ruined EM, they've also ruined one of my favorite airlines - Southwest. Free bags, gone. Open Seating, gone. No change fees, gone. This is why we can't have nice things

Bout to take off on Southwest to head back to FL.

Yup.

 

[EctopicFetus]

That's an excellent point but given how tax advantaged wealth from stock is, doesn't that actually make their compensation even more disproportionate? A pro athlete is going to lose a significant amount of their salary to the state, while the CEO can leverage their stock in ways that cost a fraction of the taxes levied againt Ohtani, Messi, or Mahomes.

Sure. The point still stands right. Re Ohtani.. take a closer look at his deal. He deferred his money to avoid paying California state taxes. The point is much of the wealth the CEOs generate is through their work. For many pro athletes it is about what they did in the past (often for other teams) and much of the money is guaranteed.

We can dive into the details. The point is when it comes to straight salary its treated the same. The comp as stock surely is different especially if it is as options. Nonetheless we get all hot and bothered by the CEO salaries but it is a tiny number of actual people. Again, smaller IMO (I dont have data) than the number of pro athletes making that same salary.

 

[EctopicFetus]

To be fair, $10mil is still generational wealth. It's just not Russian nesting doll made of yachts rich.

What if you have 6 kids.. is it? I would say not really. I guess it depends on how you define generational wealth. I dont believe there is a firm definition. I will go out on a limb and say most docs can do this for their kids and grandkids. Few want to sacrifice enough to do it (and I think thats right) but is a crazy world where it is even a possibility out of a fairly “normal” job.

 

[EctopicFetus]

Steve Jobs took only $1.00 as his salary from Apple. The rest was stock options…

Bill gates did the same but was already filthy rich from all the stock he owned.

 

[dozitgetchahi]

Steve Jobs took only $1.00 as his salary from Apple. The rest was stock options…

Right - generally the way you get wealth in the billions is to a) inherit it b) grow a business from nothing to really big, and get lots of stock as compensation along the way c) earn millions doing something else, and invest very carefully.

It’s true that a lot of CEOs don’t have salaries as massive as most think - unless they got a lot of stock as compensation in a company that grew massively along the way. (Not saying that $10-25 million plus isn’t a lot of money.)

 

[EctopicFetus]

Right - generally the way you get wealth in the billions is to a) inherit it b) grow a business from nothing to really big, and get lots of stock as compensation along the way c) earn millions doing something else, and invest very carefully.

It’s true that a lot of CEOs don’t have salaries as massive as most think - unless they got a lot of stock as compensation in a company that grew massively along the way. (Not saying that $10-25 million plus isn’t a lot of money.)

But it’s an interesting question. Jensen huang (NVIDIA), Bill gates and Buffett how much do they “deserve”. Same for JObs.. when he made $1he owned $5.5B in Apple stock. I mean truly if you had $5b $20m means nothing. If you generate a ton of “value” aka rising stock price of the company dont you deserve a piece? Keep in mind all the other manager types also get stock just not as much. I know a handful of people who joined google in their 20s just normal type jobs of really smart kids who went to fancy colleges.. They are now worth in the 8 figures. Same story at NVIDIA. Imagine joining in 2015.. Stock is up 200x. Getting 25k in stock is nothing.. thats now $~5.5m.. assuming you didnt get anything else along the way.

 

[Arcan57]

But it’s an interesting question. Jensen huang (NVIDIA), Bill gates and Buffett how much do they “deserve”. Same for JObs.. when he made $1he owned $5.5B in Apple stock. I mean truly if you had $5b $20m means nothing. If you generate a ton of “value” aka rising stock price of the company dont you deserve a piece? Keep in mind all the other manager types also get stock just not as much. I know a handful of people who joined google in their 20s just normal type jobs of really smart kids who went to fancy colleges.. They are now worth in the 8 figures. Same story at NVIDIA. Imagine joining in 2015.. Stock is up 200x. Getting 25k in stock is nothing.. thats now $~5.5m.. assuming you didnt get anything else along the way.

The sustainable value being generated for a company in most cases is by people that don't get a piece or get a much smaller piece than their contribution would indicate. It's a peculiar distortion of the American physician that when we look outside our own field, we identify with CEOs of Fortune 500 companies. Our lives have far more in common with the grinding, underpaid technical/knowledge workers that actually power those companies.

How much do CEOs deserve? I don't think there's ananswer to that. The better question is how long can society afford to continue subsidizing (tax breaks, bailouts, etc) a class that has enough power to overwrite the rules to the detriment of everyone but themselves?

 

[EctopicFetus]

The sustainable value being generated for a company in most cases is by people that don't get a piece or get a much smaller piece than their contribution would indicate. It's a peculiar distortion of the American physician that when we look outside our own field, we identify with CEOs of Fortune 500 companies. Our lives have far more in common with the grinding, underpaid technical/knowledge workers that actually power those companies.

How much do CEOs deserve? I don't think there's ananswer to that. The better question is how long can society afford to continue subsidizing (tax breaks, bailouts, etc) a class that has enough power to overwrite the rules to the detriment of everyone but themselves?

I agree. I think the reason people (I actually dont align docs with CEOs cause most of us dont actually run anything) do align is the relatively high salary. The real question and this holds true for CEOs as well is can someone else do the job just as well. This is the rub I have with unions as well as “unskilled” or low skilled workers. It’s the same for CEOs. I think 95% of hospital CEOs are complete idiots and there are thousands of people who could do just as good of a job. Again, thats just my opinion as someone who has done a fair bit of admin work and met a fair number of hospital CEOs. How long can society afford subsidizing businesses? I think it depends. In general these subsidies come with promises or in some cases firm action. Cause while they get tax breaks businesses also generate a ton in taxes, and prosperity. It can be held true for any industry but I’ll provide 2 extremes of examples of jobs.

I represent a manufacturer. I am going to make widgets (cars, car parts, batteries, tires, etc, widget doesnt matter) I dont really care if i build this plant that lets say will employ 1000 people not including management. Like any good businessman I talk to 5 states and 3-5 cities in each of those states to see who will give me what I want. Let’s pretend the average pay for each of those jobs is 60k a year. Thats 1000 fresh jobs that will pay taxes, get off potentially Medicaid, pay higher taxes, increase the value of property in those towns etc. Should I as a business just not negotiate the benefits I want? The long term benefits are real as are the short term benefits of construction jobs etc. I worked in the business world before medical school. Memphis is the logistics capital of the US (and FedEx is based there) both because of its location near the center of the US, cheap land and get this.. cheap labor. In my prior life we looked at this. At the time which granted was a while back, memphis had the cheapest labor in the US and had tons of it. So if you need unskilled labor like many distribution centers used to this was a great place to choose.

Similarly as happened recently, Amazon says we are gonna create a new HQ. They want to bring 200 high paying jobs let’s say paying 200k a year on average. Thats helps with fresh property taxes etc. Should they not try to get something for this?

If you are referring to the bank bailout or the GM bailout I totally agree. The main reason is someone else can fill that void. If GM went belly up someone would buy their assets and keep making cars likely also with the same brands especially the ones with consumer sway (like Cadillac).

The states dont give tax breaks just because. It is because they are competing for jobs and businesses. If you were to say, screw it, make it a federal law that states cant do it. Unsure if that’s constitutional but then companies can just offshore their manufacturing (as has long happened) or you would simply make the states with low / no taxes more attractive.

 

[AlmostAnMD]

The auto bailout is a great example. Could have just let the entire industry go belly up, which would have teed off the electric revolution in ways we can only now imagine. Or at least new innovators in the space. It was an entirely overblown fear that we would just.....stop making cars. Obviously there was gonna be a pain point, but now in the year of our lord 2025 we certainly would have recovered, GM would be gone, and whatever replaced them would be thriving.

Great example of effective lobbying! Something EM could learn from, for sure.

 

[EctopicFetus]

The sustainable value being generated for a company in most cases is by people that don't get a piece or get a much smaller piece than their contribution would indicate. It's a peculiar distortion of the American physician that when we look outside our own field, we identify with CEOs of Fortune 500 companies. Our lives have far more in common with the grinding, underpaid technical/knowledge workers that actually power those companies.

How much do CEOs deserve? I don't think there's ananswer to that. The better question is how long can society afford to continue subsidizing (tax breaks, bailouts, etc) a class that has enough power to overwrite the rules to the detriment of everyone but themselves?

One other point that got me thinking about fairness and circling back to EM.

Let’s say you have a true (unlike USACS) partnership. Let’s say for simplicity every doc makes 500k a year and there are 20 of them working the same number of hours per year.

The group gets a new leader and this leader figures out how to make more money and save money and through some actions this person makes it so the avg doc now makes 750k a year working the same number of hours and same staffing. So this doc who is a partner for sake of simplicity did this on the side. They also worked the same hours as everyone else and their pay also went up to 750k.

This doc took the group from 10m to 15M in pay for his docs (again, trying to keep it simple as I know there are costs etc).

My question is what does that doc deserve? What if he could magically have done this in 10 mins total, what if it took him 300 hours. Let’s pretend this increase in pay/comp is sustainable for the forseeable future.

This has weighed on my mind for some time. As docs who work for SDGs during the buyin process whats right and whats fair.

If lets say market pay was $250/hr and the SDG paid docs 275/hr but the business was well run and the avg partner made $400/hr. Is that fair?

Is it more fair if the job market was avg $275/hr and the group paid the non partner $275/hr is that somehow fairer or better? What if they paid $250/hr as part of their buy-in?

I would ask everyone on here for their thoughts on this. As someone who does admin this has been on my mind and I have my feelings but am curious what others on here think.

 

[EctopicFetus]

The auto bailout is a great example. Could have just let the entire industry go belly up, which would have teed off the electric revolution in ways we can only now imagine. Or at least new innovators in the space. It was an entirely overblown fear that we would just.....stop making cars. Obviously there was gonna be a pain point, but now in the year of our lord 2025 we certainly would have recovered, GM would be gone, and whatever replaced them would be thriving.

Great example of effective lobbying! Something EM could learn from, for sure.

Agreed. I opposed it at the time. The financial bailout IMO was worse cause they picked winners and losers (Lehman). Didn’t seem equitable. The financial bailout IMO was a bit more needed as we can not have a collapse of our whole banking system. It is my understanding that we were pretty close to that.

Re GM, we have options we always did.. that was a big mistake IMO.

 

[Arcan57]

That’s a great question but I think it’s really hard to answer it in any way that feels fair for all involved parties using real world conditions. In pondering the question, there are a couple of assumptions that come to mind in order to start framing the answer.

1) Absolute fairness doesn’t exist and pursuing it often creates bigger problems than it solves.
2) Humans are exquisitely tuned to detect differences in unfairness at the local level. Minimizing perceived local unfairness should be secondary only to ensuring a safe working environment and a wage high enough to remove concerns regarding food, shelter, and well being of one’s family in terms of creating worker well-being.
3. In modern EM, keeping a hospital contract requires a minimum of one person doing at least 0.5 FTE of non clinical time (NCT) and frequently much more NCT.
4. Splitting up the leadership role can reduce overall burden, but hospital leadership is going to want a stable point of contact meaning that there’s still one doc who’s going to be pulling significantly more NCT than the rest.
5. Clinical work is more intense than NCT, but NCT creates lingering chronic stress in levels that (in my experience) feel roughly similar to working a night heavy schedule. The exposure to stupidity, corruption, incompetence, unregulated personality disorders, and unrealistic entitlement doesn’t lessen as you do NCT it just means that the option to tell the offender to go away comes off the table.
6. If there is a dramatic increase in revenue, it’s unlikely to be the sole result of the one doc creating a solely self contained process that doesn’t rely on any buy-in or resources from the group.
7. In a true partnership, responsibilities and privileges should be proportional and in line with the talent and effort invested in the partnership.

With that pre-amble, I’d suggest something along the lines of pay admin doc(s) like nocturnists with enough clinical buy-down to let them attend the meetings needed to keep the contract. Maybe make some of their compensation at risk to discourage coasting. Have a bounty for ideas that overall impact revenue, maybe 10% for a year to encourage innovation

 

[VA Hopeful Dr]

Bout to take off on Southwest to head back to FL.

Yup.

Is it bad that I'm actually excited about the changes?

I'm freakishly tall so the idea of paying a little more for extra legroom (like I do on all the other airlines) appeals to me as opposed to fighting the masses for the good seats?

 

[RustedFox]

Is it bad that I'm actually excited about the changes?

I'm freakishly tall so the idea of paying a little more for extra legroom (like I do on all the other airlines) appeals to me as opposed to fighting the masses for the good seats?

"Just walk there with your long legs, ya freakshow", said the 5'6'' man. 😆

 

[EctopicFetus]

That’s a great question but I think it’s really hard to answer it in any way that feels fair for all involved parties using real world conditions. In pondering the question, there are a couple of assumptions that come to mind in order to start framing the answer.

1) Absolute fairness doesn’t exist and pursuing it often creates bigger problems than it solves.
2) Humans are exquisitely tuned to detect differences in unfairness at the local level. Minimizing perceived local unfairness should be secondary only to ensuring a safe working environment and a wage high enough to remove concerns regarding food, shelter, and well being of one’s family in terms of creating worker well-being.
3. In modern EM, keeping a hospital contract requires a minimum of one person doing at least 0.5 FTE of non clinical time (NCT) and frequently much more NCT.
4. Splitting up the leadership role can reduce overall burden, but hospital leadership is going to want a stable point of contact meaning that there’s still one doc who’s going to be pulling significantly more NCT than the rest.
5. Clinical work is more intense than NCT, but NCT creates lingering chronic stress in levels that (in my experience) feel roughly similar to working a night heavy schedule. The exposure to stupidity, corruption, incompetence, unregulated personality disorders, and unrealistic entitlement doesn’t lessen as you do NCT it just means that the option to tell the offender to go away comes off the table.
6. If there is a dramatic increase in revenue, it’s unlikely to be the sole result of the one doc creating a solely self contained process that doesn’t rely on any buy-in or resources from the group.
7. In a true partnership, responsibilities and privileges should be proportional and in line with the talent and effort invested in the partnership.

With that pre-amble, I’d suggest something along the lines of pay admin doc(s) like nocturnists with enough clinical buy-down to let them attend the meetings needed to keep the contract. Maybe make some of their compensation at risk to discourage coasting. Have a bounty for ideas that overall impact revenue, maybe 10% for a year to encourage innovation

Agreed. Not looking for perfect but ideas. Re point 7 this is an impossibility you always need a leader for all the points you mention above. Much of running a group is continual work and the bigger you are the more work it will take and at the same time the bigger the impact.

Let’s pretend as the head of a group I got the hospital to give us a $1m subsidy but we were making $400/hr before I convinced them of this need. Let’s pretend thats a 5 year agreement so $5m total. Do I only get 100k for the contract?

Let’s now pretend I am a big group leader and I negotiate a deal but rather than $1m for 1 hospital I get $5m for 30 hospitals. Does the 2nd person deserve more?

Regarding point 6 I actually strongly disagree. I think changes in revenue are either done by the group President / leader or someone in that role or at most 1-3 people who run the show. Whether it is educating people on better documentation, better agreements with payers or the hospitals. Thats not usually a full team effort. There are other examples. Some groups dont bill for EKGs, some dont bill for reading plain films, some dont bill for US. If a doc is able to get that changed what should happen to that revenue? You can imagine the answer would depend on how the group is doing. If the group is below avg in $/pt thats one thing, if the group is already making a lot of money then maybe the answer is different.

My point is it is complicated.

 

[Birdstrike]

My experience with private equity in medicine is they’re often hands-off owners with no interest in day-to-day operations.

At my last group, they bought the office building we leased. There was major damage to the building but they didn't fix it. There were no returned calls, no real effort to uphold the lease. It was just a flip opportunity to them, not anything to operate with any integrity.

It doesn’t shock such a group would buy a hospital and let the ER fall apart like in some post-Zombie apocalypse scene, while waiting to cash out.

 

[Birdstrike]

That’s a great question but I think it’s really hard to answer it in any way that feels fair for all involved parties using real world conditions. In pondering the question, there are a couple of assumptions that come to mind in order to start framing the answer.

1) Absolute fairness doesn’t exist and pursuing it often creates bigger problems than it solves.
2) Humans are exquisitely tuned to detect differences in unfairness at the local level. Minimizing perceived local unfairness should be secondary only to ensuring a safe working environment and a wage high enough to remove concerns regarding food, shelter, and well being of one’s family in terms of creating worker well-being.
3. In modern EM, keeping a hospital contract requires a minimum of one person doing at least 0.5 FTE of non clinical time (NCT) and frequently much more NCT.
4. Splitting up the leadership role can reduce overall burden, but hospital leadership is going to want a stable point of contact meaning that there’s still one doc who’s going to be pulling significantly more NCT than the rest.
5. Clinical work is more intense than NCT, but NCT creates lingering chronic stress in levels that (in my experience) feel roughly similar to working a night heavy schedule. The exposure to stupidity, corruption, incompetence, unregulated personality disorders, and unrealistic entitlement doesn’t lessen as you do NCT it just means that the option to tell the offender to go away comes off the table.
6. If there is a dramatic increase in revenue, it’s unlikely to be the sole result of the one doc creating a solely self contained process that doesn’t rely on any buy-in or resources from the group.
7. In a true partnership, responsibilities and privileges should be proportional and in line with the talent and effort invested in the partnership.

With that pre-amble, I’d suggest something along the lines of pay admin doc(s) like nocturnists with enough clinical buy-down to let them attend the meetings needed to keep the contract. Maybe make some of their compensation at risk to discourage coasting. Have a bounty for ideas that overall impact revenue, maybe 10% for a year to encourage innovation

These are the reasons I never pursued administration as a viable exit option from EM clinical work.

 

[Birdstrike]

Yes, stock options are way better than salary (especially large companies).

Yes, they are. Even though the initial granting of the options may trigger tax (depending on the type) future earnings are taxed at the much lower long term capital gains rate. Definitely the way to go.

Also, once the options are exercised and vested, instead of selling the shares (a taxable event) you can use them as collateral for loans, which generates cash (an untaxed event); a strategy for the super-wealthy.

 

[BoardingDoc]

My experience with private equity in medicine is they’re often hands-off owners with no interest in day-to-day operations.

At my last group, they bought the office building we leased. There was major damage to the building but they didn't fix it. There were no returned calls, no real effort to uphold the lease. It was just a flip opportunity to them, not anything to operate with any integrity.

It doesn’t shock such a group would buy a hospital and let the ER fall apart like in some post-Zombie apocalypse scene, while waiting to cash out.

Yeah, I've seen both. I've seen Steward style "bleed them until they die then file for bankruptcy and do it all over again." That said, my current pain group is also PE owned (technically more of a CMG with PE backing) and it is extremely fair comp for the field and they dump a lot of money into keeping us running as well as possible.

 

[Arcan57]

Agreed. Not looking for perfect but ideas. Re point 7 this is an impossibility you always need a leader for all the points you mention above. Much of running a group is continual work and the bigger you are the more work it will take and at the same time the bigger the impact.

Let’s pretend as the head of a group I got the hospital to give us a $1m subsidy but we were making $400/hr before I convinced them of this need. Let’s pretend thats a 5 year agreement so $5m total. Do I only get 100k for the contract?

Let’s now pretend I am a big group leader and I negotiate a deal but rather than $1m for 1 hospital I get $5m for 30 hospitals. Does the 2nd person deserve more?

Regarding point 6 I actually strongly disagree. I think changes in revenue are either done by the group President / leader or someone in that role or at most 1-3 people who run the show. Whether it is educating people on better documentation, better agreements with payers or the hospitals. Thats not usually a full team effort. There are other examples. Some groups dont bill for EKGs, some dont bill for reading plain films, some dont bill for US. If a doc is able to get that changed what should happen to that revenue? You can imagine the answer would depend on how the group is doing. If the group is below avg in $/pt thats one thing, if the group is already making a lot of money then maybe the answer is different.

My point is it is complicated.

For point 6, much of the actual change in revenue is based on the behavior of the group over time. The group president isn't going behind docs and "fixing" their documentation. There's someone (usually not the group pres) who's doing quality audits who then talks to the individual provider who then makes a consistent change that increases revenue. With the exception of insurance/hospital reimbursement negotiations, most of what increases revenue for a group isn't complex. Documenting everything you can bill for, running a cost/benefit analysis on scribes/AI/billing and coding classes, etc. aren't conceptually difficult. The revenue comes from individual docs working clinically utilizing a work flow that allows for capture of the appropriate codes.

In EM, the labor of the group is the product. The negotiator is acting on behalf of the group. The negotiatior is negotiating a contract that they, by themselves, cannot fulfill. Should they get to pocket the $1m/yr extra despite the fact that it's the group's labor and not their skill as a negotiator that ultimately is why the contract was signed?

I guess the other way to look would be to see what you'd be paying a contractor to do the thing (billing improvement, negotiations, etc) and usethat as your reimbursement rubric for the doc taking on that project. The problem is that as soon as you start incentivizing non-clinical work more highly then clinical work, you're birthing a proto-CMG.

If you're the head of an ED group staffing 30 hospitals, I'd argue that you're essentially already functioning as a CMG and the most efficient structure is going to look a lot like the org. chart of Team/USACS/etc.

 

[EctopicFetus]

For point 6, much of the actual change in revenue is based on the behavior of the group over time. The group president isn't going behind docs and "fixing" their documentation. There's someone (usually not the group pres) who's doing quality audits who then talks to the individual provider who then makes a consistent change that increases revenue. With the exception of insurance/hospital reimbursement negotiations, most of what increases revenue for a group isn't complex. Documenting everything you can bill for, running a cost/benefit analysis on scribes/AI/billing and coding classes, etc. aren't conceptually difficult. The revenue comes from individual docs working clinically utilizing a work flow that allows for capture of the appropriate codes.

In EM, the labor of the group is the product. The negotiator is acting on behalf of the group. The negotiatior is negotiating a contract that they, by themselves, cannot fulfill. Should they get to pocket the $1m/yr extra despite the fact that it's the group's labor and not their skill as a negotiator that ultimately is why the contract was signed?

I guess the other way to look would be to see what you'd be paying a contractor to do the thing (billing improvement, negotiations, etc) and usethat as your reimbursement rubric for the doc taking on that project. The problem is that as soon as you start incentivizing non-clinical work more highly then clinical work, you're birthing a proto-CMG.

If you're the head of an ED group staffing 30 hospitals, I'd argue that you're essentially already functioning as a CMG and the most efficient structure is going to look a lot like the org. chart of Team/USACS/etc.

Ill say the Team/USACS are not efficient if you are the labor. They are efficient for the PE overlords. If you arent familiar I would recommend reading about the PE world. This was a good book.

https://www.amazon.com/Plunder-Private-Equitys-Pillage-America/dp/1541702107

While all you said is right, my point is not to make it complex but rather to keep it simple to see if there is an answer.

my point is really it will never feel fair or right to folks. This is a major weakness of private EM groups.

The docs feel like I earned the pay. In many ways they did but.... did you earn $150 for that encounter or $175? That comes down to insurance contracts (holding steady for documentation).

In addition, there are groups that dont bill for the ED EKGs, if someone in the group came in and changed that it could be alone worth $4-5/pt (all comers).

If someone in the group negotiated this with the hospital and cardiology. Same with the idea of negotiating better insurance contracts. Many groups are very poor at this.

On the other hand, I completely agree that admin needs to be paid less than clinical work. Its easier, less stressful but on the other hand you are sort of always on call depending on your group setup.

Just working shifts is for most people clock in and clock out. Worry about nothing including dealing with the hospital, nursing etc. Its somewhat like nirvana.

NO perfect answer but man the idea here is super interesting to sort out what makes sense to do as a group. No perfect answer exists but I do know finding a real balance is near impossible.

 

[TooMuchResearch]

We effectively pay our admin time, including for group leadership positions, at a rate equivalent to our daytime median rate.

This seems like a good deal for people that like the work and a reasonable deal for those of us (me) that don't like the work.

They more or less just work less clinical time but have the same schedule requirements (nights, weekends, etc) as the rest of us.

 

[EctopicFetus]

We effectively pay our admin time, including for group leadership positions, at a rate equivalent to our daytime median rate.

This seems like a good deal for people that like the work and a reasonable deal for those of us (me) that don't like the work.

They more or less just work less clinical time but have the same schedule requirements (nights, weekends, etc) as the rest of us.

No need to share specifics but i wonder this.. it’s a popular question to ask about pay for dept chiefs. What’s fair is dependent on your hourly.

If your avg EM hour is $250/hr is that what it works out for admin? Does it hold if pay is $500/hr? I think it makes the most sense when clinically you are at 250 or under and the lower it goes the more it makes sense.

My prior group we paid everyone regardless of productivity based on hours worked and admin got X number of hours depending on the role. It still never really made sense since it was just some value that was given. What we earned per hour depended on collections so it was variable but it was tied to groups performance to some degree.