The buzzwords this season are “RVU-based compensation.” Back in the old days, this was known as fee-for-service, but the formulas have changed a bit, though the result continues to be an eat-what-you-kill scenario (kind of an ugly description but curiously applicable).
Like the old fee-for-service models, physicians whose earnings are based on what they produce tend to earn more than salaried EPs. The development of the RVU production-based compensation model pretty much started in California, with the four largest groups there implementing it over the past several years. The trend has been sweeping east with the highest concentration showing up in Texas right now. In fact, according to Angel Iscovich, MD, the chief executive officer of the west division of EmCare, “RVU models are less of a trend and more of a standard” for EP compensation in Texas.
ApolloMD staffs EDs in six southeastern states with straight RVU-production based incomes. “We see that the job of being an [emergency physician] is getting harder. Busier EDs, more expectations, more metrics. It is our job to try to counterbalance the increased expectations with a fair and lucrative pay model as well as organizational support via IT tools,” said Christopher Krubert, MD, the CEO of ApolloMD. The Northeast, Middle Atlantic, and Pacific Northwest remain primarily in the hourly salary pack with only sporadic bonuses based on RVUs. Because the bulk of EDs in these areas are not staffed by contract groups, the question seems to be if and when direct hospital and health care employers will get with the RVU program.
Of course, it's also crucial to understand that participation in any RVU-based compensation model does not guarantee big bucks, particularly for a graduating resident who needs time to build the skills necessary for moving patients in a timely manner and completing spot-on documentation. If you are interviewing with an employer with this kind of income model, find out how long it takes to reach average levels for incoming physicians and what the earning range is.
The following reports are based on compensation being offered by employers who are hiring this season, not on the overall incomes available in a state. The figures are from employee and RVU-compensation models with 1,650 annual hours as the base average. Though employee benefit packages can range in value from $20,000 to more than $75,000 (with group-funded maximum retirement contributions), they have been averaged into the overall annual compensation levels.
The 10 states of the Southeast are the strongest this season, with four states in the region making my top 10 list for compensation this year. Leading the way is Mississippi, with an average of $350,000 and a high of $575,000 with a coastal group offering up to $350 an hour with partnership. Florida and Georgia top out at $500,000 packages being offered by groups a year after partnership is attained. The average in Florida is $340,000, and is $330,000 in Georgia. Notable is a high $225 an hour plus benefits being offered by a southeastern multihospital employer for transition team physicians as their EDs are brought in-house. The bulk of the states in the Southeast average annual packages of $300,000, including North and South Carolina, Louisiana, Arkansas, and West Virginia. Tennessee comes in a little stronger with a statewide average of $310,000 and a state high of $390,000. Alabama comes in with a statewide average of $280,000 and pockets of compensation as high as $420,000 from straight RVU compensation.
Last year's leader, the West/Southwest, still comes in strong due to the inclusion of RVU-based compensation leaders, Texas and California, but most of the other states in the region drag the numbers down. The average earnings in Texas are $205 per hour and $350,000 annually, and the high is $480,000-$500,000 with RVU-based compensation. California stays in the top 10 because of the heavy presence of groups paying straight RVU compensation; it averages $350,000 as well. Also keeping the west strong are New Mexico and Oklahoma, with averages at $340,000. Highs in both states top $400,000, especially with smaller private groups with mostly RVU-based incomes. The other five states drag the region's averages down. Lows in Hawaii and Utah barely reach $200,000, a moot point due to a lack of job availability anyway. The highest dollars available in Arizona are in the western part of the state, and top out at around $290,000 with state averages closer to $240,000. Nevada averages are about $260,000, and Colorado still expects you to pay them for the privilege of living there with averages under $250,000.
As usual, the 13 diverse states of the Midwest come in third with Ohio, Illinois, Indiana, and Nebraska averaging $300,000. Highs in Illinois top $430,000 via RVU compensation, and the highest numbers are found in Kentucky at $500,000 with group partnership. Indiana and Wisconsin see highs at the $400,000 level, and the average in Kentucky comes in at about $290,000. The high in North Dakota is $215, and the low is $70 an hour in South Dakota. Kansas and Iowa are offering highs in the 350,000 range and averages at $320,000. Nebraska has virtually nothing to report except for one instance of $203 per hour. Minnesota logs the high income at $330,000 but averages around $260,000. Missouri tops at more than $210 an hour in the Ozarks and averages $290,000 annually. Also notable is the $50,000 sign-on bonus offered by St. John's in Joplin. Michigan, as usual, comes in at the bottom of the pile with a $250,000 average, though Detroit, historically a high-paying city, is not showing much opportunity this season.
The Middle Atlantic region is starting an impressive “catching-up with the Jonses” run with highs in Pennsylvania at the $400,000 level, primarily in the western part of the state and averages in New Jersey and Maryland at $330,000 and $340,000 respectively. Baltimore and western parts of Maryland are leading the state with income packages and sign-on bonuses ($40,000 in Cumberland, for instance). Pennsylvania's state average is $280,000, and Virginia comes in at the same level, but also offers highs at about $300,000. Delaware and Washington, D.C., had nothing to report, as usual, which means no news is, in this case, not so good news.
Some day I hope to discover how emergency physicians can afford to live and work in New York, with its lowest average pay day and the highest average cost of living in the Northeast. There must be some underground supergroups paying decent dollars, but I haven't found them yet. Average is $250,000, and highs come from MedExcel at around $330,000. Massachusetts and Connecticut post the highs for the region at $360,000, and both average $285,000. New Hampshire comes in just under that with an average of $270,000, and Vermont has a respectable income high of around $300,000. Maine and Rhode Island average between $240,000 and $250,000, but highs remain under $300,000.
And finally, here comes the Pacific Northwest — way down! High in the region is $300,000 in Washington, with averages there and in Oregon of around $260,000. I found an annual package at $290,000 in Wyoming, but that was a one and only. Montana and Idaho did not report this year (after some rare activity last year), and Alaska is off the map for emergency physicians again this season. If you are determined to try life in an igloo, contact the Indian Health Service, which usually has at least some locum shifts.
These are entry level numbers for new hires, reflecting first- to second-year earnings (particularly with partnership bumps in year two) but do not include perks or sign-on bonuses unless specifically stated. The nationwide level to be achieved appears to be a $300,000 package comprised of an hourly salary, incentive bonuses, and basic benefits. Those employers coming in higher are considered above the median, and those coming in lower are going to have a tough time recruiting in my opinion!
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Ms. Katz is the president of the Katz Company, an emergency medicine consulting firm dedicated to providing expert physician recruitment services and training emergency medicine residents in effective job searching.