Ask yourself a question. Have you ever been directly shown exactly what is billed and paid in your name as a practicing emergency physician? If not, why not? Would a pro athlete allow such a screen? I am not just talking about those of you working for investor-owned contract management groups but all of emergency medicine, especially those who work for supposedly fair groups.
Numerous groups now advertise using words like “democratic” and “equity ownership” after the American Academy of Emergency Medicine (AAEM) awakened the specialty to practice issues. Despite this verbiage, most are not how they present themselves. The one clear piece of evidence is the basic fact that most emergency physicians, no matter the work arrangement, do not ever see exactly what is billed and paid in their name.
Ed Garvey, the former executive director of the NFL Players Association, spoke at one of the first AAEM annual meetings, and basically said this situation makes us dumber than pro athletes. The point, of course, was not that we were globally dumber, but that we don't measure up on financial oversight of our professional careers.
Think about it; pick your favorite (or least favorite) highly paid pro athlete, and ask yourself if he would ever say to his agent, “Negotiate my salary with the team, and then keep that secret from me and pay me whatever you want.” This is exactly what we do when we have no idea of the fees paid on our behalf. We get some kind of ballpark idea about what sounds like a good salary and accept it. We have no clue about the actual amount of revenue we generate to establish where one's professional compensation should lie.
It is clear to me, from my years on the AAEM board and decades of looking at emergency physician contracts offered to my residents and other colleagues, that it is the exception rather than the rule for an emergency physician actually to see what is paid in his name. Huge numbers of emergency physicians think they are getting a fair deal because they are told their group is “democratic,” “equitable,” “physician-owned and -operated,” and so on.
A couple of quick rules:
- If your group does not make provisions to let you see exactly what is paid in your name, you are likely getting ripped off.
- If your group is in more than two hospitals, it is probable that someone is making a pile of money off the top.
- The more hospitals your group is in, the more likely you are part of a big pyramid scheme where huge amounts are going to a few individuals.
It is really pretty simple, though: if you can't see what is paid in your name, someone is making money off you. Why else do they keep the information from you? I have written about how corporate groups can take up to about one-fifth of your revenue for profit. (Common Sense, the AAEM Newsletter 2010;17:8; http://bit.ly/VPb9Tk.) Other more creative groups use tricks to ensure that the rank-and-file docs who put in the majority of the clinical shifts and generate the income remain dumber than the pro athletes. All of them have the same basic foundation: you do not see exactly what is paid in your name so you cannot figure things correctly, such as:
- The missing-piece-of-the-pie trick: In this one, the working docs as “equity owners” are shown that they split up the pie in a fair manner, usually on an RVU basis. What they aren't shown is that the true owners have already taken an oversized piece of the pie as profit. If one could probe, this slice would be labeled a management fee usually accentuated by a layer of profit from self-owned medical service organization (MSO) functions of billing, collections, and the like.
- The multilayered partnership ploy: Here the junior docs are told they will eventually rise up the food chain to become full or senior partners. Sounds great, and, sure, if the time period and the buy-in are reasonable and you truly become an equal … well, wonderful! The problem is that you never really become an equal in these multihospital schemes. There are percentages off the top for site directors and regional directors, and often there is the same missing piece of the pie layer of profit for the true top dogs who have a piece of the MSO.
- Our books are open; we show them to you: In this scheme, the words “seeing exactly what is paid” become important because a large “noncorporate” group in the guise of transparency will send its doctors detailed reports listing a “fee” for each of their patients. The docs think they are getting a fair deal when in actuality the “fee” is not what is collected and is well below even Medicare rates.
The pay in the academic arena where I work is based mainly on rank, and you attain rank by publishing papers, teaching well, being a good clinician, and going the extra mile. Small bonuses are given for clinical productivity. I send every one of our doctors the data on what they generate in professional fees. Unfortunately, in our poor community, not a single faculty member covers his salary, expenses, and benefits, no matter how many clinical hours they work. They chose to work where the pay is less, but at least they get to see the true economics. Those of you who work for a self-described fair group, large or small, need to ask yourselves the fundamental question of why you never see exactly what is collected in your name.
Technically, you are entitled to ask the billing company for a full accounting of what is billed and paid in your name. In reality, asking for that puts your job at risk because most of you can be terminated without cause. AAEM failed a few years ago when it tried to get the federal government to mandate that billing companies send this information directly to the physician without a request; certainly this is something that emergency medicine professional societies should support for their members. If you are in one of these “fair” physician groups where you have a “vote” (usually it is diluted), theoretically you could change the situation but that depends on your circumstances and what actual power the rank-and-file possesses. It is my firm belief that if all emergency physicians saw exactly what was billed and paid in their names, we would have a much different structure to the practice of emergency medicine today.
The apologists for the current state of affairs, most of whom have made a bundle off the sheep status of the bedside emergency physician, will rankle at this article and say profit margins are thin, they take the risk, and they generate value in their management role. I have no problems with others who provide a valuable service making a reasonable income; they deserve it. What they do not deserve is the right to shield this information from the physician who is taking much more risk, is responsible for honest billings, is at the bedside nights and weekends, and has put in years of expensive training. We could discuss other tools to help the physician, such as the fee-splitting statutes, but they rest on the fundamental principle of physician access to the true financials of their practice. The emergency physician can learn something from those dumb jock pro athletes.
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