Rick’s Rants: Bracket Creep in the ED

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN
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Matthew L. W., M.D. -

I love you Rick and EMrap, but....

I get tired of insinuations that EM docs are overpaid and are billings are not deserved. Hospital and insurance administrators are overpaid. Internet influencers, athletes are overpaid. Medical mal lawyers and expert witnesses are overpaid. EM docs who are fighting it out in the frontlines with the overcrowding, stress, malpractice risk, infectious dangers, violence dangers are underpaid. Who routinely saves lives and makes little boys elbows feel better? When was the last an insurance executive saved someone's life (perhaps the opposite when they deny care)? We are the white knights and we deserve every dollar we get and more...

W. Richard B., M.D. -

Matt,
Thanks for writing -- and I'm glad you still love me. Make no mistake about it. I think EPs have the hardest job in medicine -- hands down. No argument. I did it for 34 years. But, I think we need to be cognizant of the economics. There has to be some limit. The reason that our health care system is the most expensive in the world (with Canada at $7,000 per person and the U.S. at $11,500 with same or better outcomes) is very simple -- EVERYTHING costs more in the U.S. And physician salaries are right there on the list.

Based on the salary surveys I'm seeing, EPs are making $350,000 a year -- some over $400,000 and some a lot more. Ten years ago the doctors in our group did all the same challenging things you listed for $200,000. The rate of rise of EP compensation has been remarkable -- 36% in the last 10 years according to a Barbara Katz survey (and full-time hours dropped from 1,632 hours to 1,560). Matt, you say that EPs are underpaid, what do you think is fair? $400,000-$500,000? You have to remember that PAs and NPs in the ED make about $130,000. Are you three times more productive? Do you generate 3 times the number of RVUs than the PAs/NPs? Sure, there are absolutely times when the skills of an EP are essential and life-saving, but everybody certainly doesn't need the expertise of a boarded EP.

Lastly, the Katz survey noted an 18% decrease in the overall availability of EP jobs nationally in 2019. Now put this into perspective with the 11,000+ new EP grads that will be cranked out in the next 5 years and the fact that there will be a ton more PAs and NPs looking for jobs (2019 saw the most PA graduates since 1975 -- over 9,000! -- and there over 60 new PA programs about to come online. And a similar trend is occurring in the NP world).

So, you'll get no argument from me that you work hard. I think some of the stress of being an EP is because many EDs (most?) are operated poorly. Poor throughput, holding admitted patients, 12 hour shifts, wrong staffing mix -- stuff that should be simple to fix -- if the administration, medical staff and ED group managers had the will to fix them. But bottom line, I'm on your side. I think being a really competent EP is a wonderful career to strive for. I tremendously admire EPs who do it well. But when you look at the numbers, we are paid well on average and we very well may be at the high water mark for physician salaries.

Matthew L. W., M.D. -

I see your points, that said
1. with inflation rate our salary increases our not out of line- 36 percent vs 21 percent national 10-year inflation rate. Again compare that with insurance company CEOs and hospital CEO's. With corona, our salaries are dropping and likely will come close to 21.
2. physician salaries only make up 8.6% of healthcare dollars

And I get it that we have done a terrible job guarding our profession with the proliferation of residencies and allowing mid-levels to do the same jobs we used to do in many groups- as a replacement and not an addition (not in mine, fortunately). We make a big deal about board-certified emergency physicians can only handle the complexities of the ED and then we allow one ED MD to run in ED with 3 mid-levels and call that safe just to save money for a behemoth contract group. I blame the CMG's take over of our profession as the root cause of this, not front line ED MD's.

Basically I'm arguing to stop making our well-desevered salaries from many years of training, hard work, and daily life saving work to be the scape goat for a system where we are good guys doing the right thing day in and day out and others whose boots aren't on the ground are making the big bucks.

W. Richard B., M.D. -

Matt,
I feel your angst. But you make comparisons to CEOs of insurance companies and hospitals. I agree that insurance company CEOs are grossly overpaid -- this is a problem with most publicly traded companies in the U.S. You've seen the comparison with CEOs in Japan -- they make a third of what's paid in the U.S.

BUT, do you have the skills to run an insurance company -- be honest. To get these jobs you have to work your way up the ladder and in the process, most don't make it. It would be unusual to be a CEO and under 50. Doctors make at least $250,000 the day they graduate -- all of them (and that is the minimum). And there is no ladder where we climb over each other -- everybody advances

You mention that doctors make up only 8.6% of the healthcare dollars. I saw a chart that says physicians and clinics make up 20%. And regarding the CGMs -- many of their contracts were bought by giving senior partners of private groups a big payday while leaving the rank and file the chore of ultimately paying for the sale -- and generating a profit for the CMG on top of it. So some owners of the smaller groups are certainly not wearing the white hats when it comes to their relationship with the pit docs. And face it -- the job of the CMGs is to make money -- especially if there is Wall Street money involved. How did CMGs get so strong -- we let them. But the train is certainly out of the station regarding that conversation.

Bottom line -- we need to fix our EDs so that the work environment is conducive to a long happy career. This requires that the overpaid CEOs along with the ED group leaders need to make it happen. Complaining about your salary because you work in a poorly run ED that has multiple sources of unneeded stress and angst is really not the answer.

Take a look at the 2020 EP Salary Survey by Barbara Katz and the article, "It's Still the Prices, Stupid: Why the U.S. Spends So Much on Health Care, and A Tribute to Uwe Reinhardt" in Health Affairs, January 2019.

Thanks for writing. I enjoy the good-natured sparring with colleagues.

sunil a. -

I agree with you 100%, I have had similar experience with my family member and myself as a patient unfortunately. Did not feel like complaining against my specialty colleagues. Too bad system is screwed up, don't know where to start from.
Regards,
Sunny
Sunil Ahuja, MD, FACEP

W. Richard B., M.D. -

Sunil,
This bracket creep issue is something I believe most all of our families will experience when they go to the ED. I think many (most) EPs are unfamiliar with what is being billed under their NPI number and would be very surprised if they actually saw what the bills were for their service. Do they know the dollar amount that a level 4 or 5 is being charged? I bet less than 10% of EPs know what their fees are.

I think the U.S. population has seen what happened when the pandemic drove down ED visit 30-50%. They found lots of other ways to get care -- do nothing (many conditions are self-limited), go to an urgent care (there are about 10,000), go to a CVS Minute Clinic (there are 1,200 with more coming -- and they will be expanding to take on primary care -- BP. cholesterol, diabetes, etc). 70% of the US population lives within 3 miles of a CVS -- talk about access! Walmart is a sleeping giant that is starting to wake up and then there are tons of telehealth options. Everybody wants the ED's more minor cases -- they want to attract that 80% of patients that EDs discharge. EDs will never be able to survive on just the admitted patients. Losing patients to providers that charge less (not $500 for a sore throat) and make patients wait less should be where EDs focus their efforts. We'll always get the admitted patients -- where else are they going to go? It is the discretionary patients, the ones who can decide where to get care, that we should be trying to attract -- but we have to treat them rapidly and value their time and they have to be charged fairly. We can do this with the appropriate staffing (smart use of APCs) and making it clear to the community that the ED (and its attached Urgent Care center) will provide the most credible care -- fairly priced.
Rick

Xander Merboo -

I love your diatribes and have found your insights spot on - thanks for sharing!

Perhaps you'd humor my own rant. I'm this episode (I think?) You mentioned the scarcity of EM physicians in places like Montana and Iowa. Perhaps you could help me remind all those residents of the LA basin that, yes, California actually extends farther north than the grapevine. The SoCal centric perspective does a great disservice to the other 80% of the state; Including the very rural north, where social services, access to healthcare and healthcare resources are scarce and overtaxed. I've worked in emergency departments in Eureka, Crescent City, Redding and Paradise (before the town burned down) and can assure listeners that you don't have to go to Montana (where I also worked) to find scarce resources; there's lots of spots right here in California, just outside the LA basin

Thanks!

W. Richard B., M.D. -

Xander,
Thanks for the feedback. It's nice to know that some people out there still have some good sense. Regarding your rant -- absolutely. There are thousands of hospitals out there (the vast majority) that don't have residencies and don't have all specialists on call all the time. It is much harder to work at these smaller hospitals than the ones that have all the coverage. There are tons of hospitals that have one EP in the ED with maybe some PA/NP coverage. It seems much of the CME comes from the EP training programs and they don't have the perspective of the single-cover ED. Also, a lot of the rural EDs and many community EDs are covered by non-EM-boarded physicians who are very open to getting more focused CME. So, yes, I agree -- we need more of an appreciation of non-Southern California EM. Thanks for writing. Rick

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