Group Decisions – Types of EM Jobs

Jeff Pinnow, MD
YPS Communications Chair

This issue’s article is meant to be a refresher for those new grads who haven’t secured a new position yet and for those who may be thinking of a change and aren’t sure what type of job they may be looking for. YPS has received several requests to review the types of jobs that exist in EM, so the intent of this article is to familiarize those upcoming grads and those looking for a new job with the basics of emergency medicine groups.

The first decision one has to make is academic vs. non-academic emergency medicine. Most grads will practice in non-academic environments, but there are some who prefer academics and will want to pursue that career course.

The academic practice is ideal for those physicians who want to teach and influence the development of future emergency physicians. Academic physicians value the teaching environment, research opportunities and lifelong personal learning. As an attending physician, most direct patient care is through the residents. The attending oversees several patients, has to ensure proper care is being given by the residents, and is responsible for training and educating residents during busy shifts. Academic physicians typically work a set amount of hours and are salary-based, since RVU -based income may influence the amount of teaching that is delivered. The physician will typically work less clinical shifts since a portion of their responsibilities will include education and research. This may lead to longer job satisfaction and less physician burnout. The hospital is typically responsible for all billing and collections, and malpractice is generally covered by the employer. Since academic programs take place in academic centers, there is little concern about contract maintenance, and the physician is considered an employee of the hospital. Other than patient care, the main responsibility of the physician is a continued commitment to education. These positions typically require fellowship training to attain, so the extra years of training are an important consideration to factor into your decision.

Now on to non-academic emergency medicine, where several options exist.

Hospital Employee

With this option, the emergency physician may be hired directly by the hospital to staff the emergency department. The physician generally negotiates his or her own individual contract with the hospital administrator and is considered a hospital employee. This option allows the physician to sign on as an individual and negotiate the best contract possible. Individual contracts may be salary, hourly or RVU fee for service based. As a hospital employee, the physician is given the additional benefits that all hospital employees have. These may include medical and dental insurance, retirement funding and CME funding. These benefits are typically calculated into the physician’s total compensation package, so actual salaries may be lower than those in contract management groups or democratic groups. In return, the physician is considered a hospital employee and is responsible primarily for patient care in the emergency department. This type of practice ensures that physicians are not vested in their own practice and therefore have less of a “practice group” mentality but rather a hospital-supporting role. The physician will answer to the department director, who, in turn, reports to administration. The hospital is responsible for billing and collecting, other administrative duties and malpractice insurance. There are no contracts to maintain, limiting the physicians responsibility to his/her personal performance only.
Contract Management Groups

Corporate groups are those that are managed by corporations as opposed to being run by the physicians in the group. A contract management group (CMG) holds contracts with individual hospitals with the promise to provide physician services, and it, in turn, employs physicians to fulfill those contracts. From a hospital perspective, because of the large network of contracts, billing services and physician employees, CMGs may be able to offer lower contract costs to smaller hospitals, which are also looking at the bottom line. The contract management group deals with all the financial management and human resources aspects and subsequently pays the physicians for their work within the contracted ED. The physician may either be employed directly by the group or work as an independent contractor on behalf of the group. Traditionally, the physician provides clinical care and has little input as to the finances of the group and how they are to be managed. Physician employees of CMGs typically work for a salary, with bonuses tied to patient satisfaction and resource utilization. Often, CMGs may take a disproportionately large part of the emergency physician’s billed and collected professional fees as remuneration for administrative services provided by the group.

As with smaller democratic groups, the need to maintain the contract still exists, and physicians still must maintain strong relationships with hospital administration. As an employee of the CMG, the physician must also maintain good relationships with the CMG administration, thus adding an additional layer of responsibility on the emergency physician. The physician thus functions as an employee of two entities and may have difficulty in keeping both employers satisfied. The fact that CMGs are corporately run places an emphasis on the bottom line and profits. This emphasis may alter patient management practices on the part of the physician. This is part of the reason that many states have laws against the corporate practice of medicine. The advantage of belonging to a CMG is the ability to work at multiple locations while still being employed by the same employer. This may be attractive to young physicians unsure about what size or type of ER they want to work in or what location a physician wishes to live in.

Democratic Group

This is the type of practice endorsed by AAEM. In this type of group, member physicians are equal partners in terms of having a vote within the group’s operations. Members are also business partners that share a portion of the collected revenue, vote on important decisions, and are active in the group, and subsequently, with hospital politics and committees. In this arrangement, the physician is able to collect the largest portion of services billed and monies collected on behalf of the physician. The group is responsible for maintaining its own financial management, human resources, billing and coding, and most importantly, contract management. Such obligations typically entail having a senior member of the group direct most of these management operations.

While members of the group are equal, one may be required to start out as an employee of the group, rather than as a partner. After an agreed upon time has passed, which can range from 1 to 5 years, the employee may then “buy-in” to the group and become a partner. The buy-in often is an outlay of money required on the part of the physician, usually paid via reduced reimbursement of the physician until a certain amount of money is accumulated. Some groups may have other processes for the buy-in.

True democratic groups should have an “open-books” policy, where the physicians are kept up-to-date with the amount of collections, expenses and the salaries/reimbursements to the group, as well as the rest of the partners. As either an employee or partner, the physician may still operate as an independent contractor. As an individual business entity, the physician must manage his/her own administrative tasks including medical benefits, retirement accounts, and CME funding and tracking. These extra tasks often require hiring various professionals (i.e., lawyers or accountants) to help alleviate the physician’s burden, which may offset the extra income earned in a democratic partnership.

Keep in mind that hybrids of the above mentioned groups do exist, and one should research each respective employment opportunity carefully to decide which may serve his/her needs the best. Several community-based hospitals do train residents through university affiliations, and some academic programs may in fact contract their ED staffing to independent groups. These hybrids may be suited for those who enjoy teaching, but not full time.

Personally, I work in a community-based hospital and am part of an independent group. This hospital possesses family practice, internal medicine and OB/GYN residency programs. All three specialties send their residents through the ED for training and allow me to teach on a limited basis. This allows me to continue and refine my own practice of emergency medicine, while also giving me the chance to teach residents; the best of both worlds.

Locum Tenens

If, after reading this article, one still cannot decide how and/or where to work, locum tenens may be an option. As a locum tenens physician, young doctors have the most freedom to explore what type of emergency medicine practice is best for them. As the name implies, most positions of this type are temporary and based on the needs of hospitals. Locum tenens can be as short as a month (less sometimes) or as long as a contract can be extended. This gives the emergency medicine professional a say in where and how long a period he or she wishes to work. Locum tenens positions are available in all parts of this and other countries. Typically, the compensation is on the higher end due to the fact that most EDs requiring locum physicians are understaffed and in need of board certified physicians. The disadvantages include having to assimilate to new hospital practices with every move, and the potential lack of long-term physician relationships that are crucial to quality patient care.

So there you have it; a quick review of the types of practices in emergency medicine. Many physicians will transition between these various groups over the course of their careers, so if one doesn’t suit your needs, you may always try another avenue. As a board certified emergency physician, the job opportunities are numerous. There is no right or wrong type of practice group; it comes down to matter of personal choice. As mentioned previously, AAEM supports the personal and professional welfare in each EM physician and feels democratic groups offer more fair and equitable practices. Each type of group comes with its own set of pros and cons, as do all choices in life.

Good Luck.