Beginnings « Ten out of Ten

There are many different ways to wear a pair of wrinkled scrubs.

The initial choice between community vs academic medicine was easy, since the latter requires the double whammy of research and med student/resident supervision, for half the pay no less.

My search was confined to specific locations, and the community ER spots available locally were divided between giant emergency staffing companies and physician-owned democratic groups.

This was another easy decision. Putting them in the softest light possible, the large staffing companies like EmCare offer job portability and outstanding benefits. In truth, these corporations exist because business-savvy executives have been fleecing business-stupid ER docs since the beginning of the speciality(1). Do I want to take a substantial paycut to fund non-physician (or defunct-physician) corporate heads? Mr. William Sanger, CEO of Emergency Medical Services Corporation (EMSC), the parent company of EmCare, takes down $1 million in salary + bonuses annually, which seems reasonable but then there’s all the rest: EmCare also paid out $4.9 million to BIDON, Inc, a consulting firm owned by Sanger and two other EMSC partners, EmCare bought $56 million worth of it’s own stock for its executive stock option program, of which Sanger owns 450,000 shares valued today at $14.8 million, Sanger received a bonus of $12.5 million for assisting with the sale of EMSC from Laidlaw to Onyx(2) — all this money originating off the backs of the docs doing the actual work of emergency medince.

So instead I went the opposite route, and signed on with a small democratic group of docs that staffed the ER of a midsized hospital within a growing community. There was a lot to like. You were paid per patient seen instead of a fixed hourly rate, helpful in fighting off resentment towards the masses of non-sick patients that overcrowd an ER. Overhead was minimal, which allowed most of the money generated by the group to find its way back to the docs. With just a handful of members you could have a real voice in the decisions made around you.

For all the benefits of their small democratic setup it was still a double-edged sword, the other side being they held only the one contract to staff a single hospital’s ER. Hospital administration could, theoretically, terminate the agreement without cause at any time leaving the jilted docs at best at the mercy of the incoming group and at worst out of a job. But the partnership had been extremely stable — the group had contracted with the hospital for an uninterrupted eighteen years with no partner leaving the group in over ten. Quality had not been an issue: patient satisfaction scores were excellent and no lawsuits had been filed in over eight years. The contract cost the hospital nothing. Why, then, would hospital administrators ever be motivated to terminate the contract?

(1) Emergency Medicine residents in particular: do yourself a favor and read The Rape of Emergency Medicine by James Keaney, MD prior to your job interviews.

(2) http://www.aaem.org/media/story.php?contentid=139

AnonEDMD Says:

April 7, 2009 at 7:55 am

I am in a similar situation – partner in a medium sized democratic group with one stable contract. TeamHealth is infiltrating most of the local facilities and taking over the contracts. Why do the hospitals choose to go with a “pimp group” when patient/MD/nurse satisfaction is much higher with democratic groups? I don’t know, but I suspect there are substantial kickbacks going on.

ERP Says:

April 7, 2009 at 7:58 am

We went through something similar two years ago. The fact is that big corporate ER groups simply can afford to buy the contract. The may offer a good faith “donation” of a million bucks or more to score a good contract. What private small group of 6 docs can afford that? In my area, there are examples of all types of practises (democratic, corporate, and hospital owned) – the ones that are small(ish) and private (democratic) still often have to make generous donations to stave off the onslaught of EMcrap, I mean EMcare and TeamHurt I mean TeamHealth. The downside of joining these small groups though is that many of them mainatain a stranglehold on partnership. It may take 5 years plus an insane buy-in to become partner where you make real money. They often terminate the younger docs to avoid having to divide the partnership pie up further (unless the volume and reimbursement has dramatically increased). Many also have inadequate coverage – for the same reason, so the partners can have more of the pie. They tend to employ lots of midlevels to stave off the need to have another partner.
That said, the best (and only) way to avoid getting sacked in favour of the corporate guys is to get in good with the private docs. Their opinions matter more the hospital than the ER docs since it is their patients that get admitted and have surgery, etc. They could send their patients elsewhere so if they really like the ER docs, they will go to bat for them. Many private docs HATE the idea of corporate Emergency Medicine as much as ER docs do and fear poor quality and/or non ER trained or boarded ER docs mucking with their patients. This was the case with our hospital. The private surgeons and internists basically spoke up to administration saying they were firmly against a corporate group taking over. They told them of their displeasure with nearby hospitals that used TeamHealth docs. This greatly helped us (as well as us making a nice donation to the hospital’s new ER – although not a million bucks!)

secondopionion Says:

April 7, 2009 at 2:06 pm

I actually work for an EmCare contract and agree with the two comments above. In an urban area sometimes the choices are limited. I also work PT for an academic center. That said, sometimes, but not always, a big corporate group can pay similarly to a democratic partnership because of economies of scale. They own the billing company, the own the malpractice company… etc.. So even after the non-doc’s get their stock options you ended up about flush. That’s not always the case but there are several corporate contracts where the docs make a bundle and the admin work is minimal. I wish the specialty of EM was not so broken (the first generation soaked up the contracts and ate it’s young by skimming off the top and then the corporate guys are now eating the first generation up). In no other specialty are physicians beholden to so many bosses (patient, hospital admin, corporate group, medical staff). That’s the perils of being a contracted group. EM would have to band together to fix it and it wouldn’t be pretty, may not even be possible (doctors don’t strike!). If you’re involved in leadership in EM that means you are the liaison between the docs and the “Man” in all his forms and you know a sad truth: EM docs are some of the best docs in the hospital but we don’t have enough political power, often, to change our perception as triage docs. Sad state. I hope your contract issues work out 10/10. Academics may pay nothing but it’s the place where you can yield true political power (at a county facility at least) and practice true medicine. Might be worth the pay cut, I don’t know.

roxanne Says:

April 7, 2009 at 7:39 pm

At my hospital we are on our fourth group of corporate sponsored MD’s in eighteen months. Nothing our democratic group did could stop them from taking over. The result: a never-ending procession of physicians who work at various hospitals in our town. None of them know us; we don’t know them, they are not invested in the hospital or the ER. It’s been very, very bad. How to ruin an ER: do what we did.