A friend from Maine recently sent me the front page of the Bangor (Maine) Daily News with the lead headline “Hospital visits for some Mainers could become more costly.” The news was that TeamHealth, “a company based more than a 1,000 miles away,” — no regional bias there of course — had taken over staffing for several of the regional emergency departments.
Most importantly, these ‘foreigners’ might begin “balance billing,” for the amount of ED physician bills that was not covered by the patients’ insurance. While the piece went on to cover the issue of balance billing, its prevalence across the country and what Congress might do to address it, the piece made my mind wander across the landscape of how much we, as emergency physicians are paid and what are the determinants of that value.
I’m happy to say that emergency physicians today make a heck of a lot more than we did when I started. My hourly rate of compensation today is over four times that when I started. Some of that is inflation, of course. My first house cost $27,000. But most of it is due to the well earned appreciation for the difficulty of what we do. There was a time when our colleagues thought just about anyone could do our jobs. Not so much anymore.
I enjoy telling the story of talking to a cardiologist in a grocery store in Nantucket who came there on vacation and thought he could work a few shifts in the local “cottage hospital” ER to pay for his trip.
When I asked how it was going, he began shaking his head like he had PTSD. “I’ll never try this again. I’ve never been so scared in all my life,” he said. “I was the only one there. I flew out four patients. One had a subdural bleed. Three others were from motorcycle accidents.”
“Sounds like an interesting night,” I said, thinking I might consider doing it.
“You’re sick, you know that,” he said still shaking his head.
“No,” I said, trying to be sympathetic to his concerns. “It’s just that that is what I’ve been doing for years.”
“You can have that job,” he finally said with an admiration that I realized was decades in arriving.
Returning to my analysis of the present situation, why are we paid what we’re paid? What are the factors that determine our monetary worth? And when is it right or wrong to demand more from the patient?
The first thing to recognize is that insurance companies only pay what is negotiated and no more. They aren’t bad. That’s just how they make their money. But EPs may not always have the negotiating power to get what we deserve. That’s why I happen to appreciate the TeamHealths and EmCares of the emergency medicine world, who are willing to take the heat from the newspapers like the Bangor Daily News or the New York Times over this issue. You may not like the idea of contract management groups, but they bring business clout to the negotiating table that has raised the tide of compensation lifting all our boats.
Our worth, though, is not just negotiated by others. We have to look out for ourselves as well. We have to make individual determinations of our value to certain situations and demand the appropriate reward.
Factors that determine value
What are the factors that determine the monetary value of any service? I don’t begrudge the diesel mechanic who works on my boat at over $100 per hour. But what does that say about my value?
The first value is scarcity, which is rooted in intellect and command of a unique base of knowledge. As I see the incoming EM residents I realize that they are the top of their respective classes and worked long and hard just to get a seat in on this train. As for unique knowledge, my dear friend Greg Henry is famous for saying that his PAs and NPs know 90% of what he does. It’s the other 10% that they don’t know that makes him indispensable.
Value is also determined by availability. You can never overestimate the value of the fact that emergency physicians are available 24/7/365. I wrote a piece once about a stabbing that occurred in our emergency department. Beyond the horrific events and its trauma to our staff, the staggering fact was that our ED never stopped functioning…
Stress associated with the job also is a determinant of value. Professional football players are paid high salaries at least in part because they can do something that most people cannot. The same goes for us. Anyone can catch a football. But can you do it knowing that a 200-pound linebacker is going to smash you as soon as you touch it? Or before, for you Saints fans. It’s the nights like the one that my cardiologist friend had where we determine our value.
The length of the career is also a determinant of value. It is true that judgment can continue to improve with age. But as I like to tell those who ask why I have largely retired from the full time practice of emergency medicine, “working the ER solo at night is a lot like flying a jet. It can be hours of boredom on autopilot interspersed with moments of terror. It’s a young man’s game.”
The most important value, however, is the value of the product. Most people can do without a lot of things. But in the end, they will sacrifice almost anything for their health. We should never take advantage of that ultimate worth in leverage against a needy patient. Likewise, we should never lose sight of the incredible value of service that we render.
The Public’s Value of Emergency Services
The reality is that EPs are some of the brightest, hard working folks in the world, who are working under incredible stress night after night for what can seem like a brief arc of a career. But that only has an impact on our compensation if the public sees that as well. Patients don’t really care what we charge them, if their insurance covers it. But they are paying a fortune in premiums for health insurance that tries to pay for everything. And that just doesn’t work. The ambulance that brought your patient may be charging as much as you do. The physical therapist who tells the patient to bend his injured knee may be doing the same. That’s why we must be present at the negotiating table when insurance rates are set. And that is the real value of our professional associations.
The concept that perception is reality also has an impact on our perceived value and compensation. My wife is quick to remind me that emergency physicians are the “plumbers of the world of medicine.” She usually says that when I’m preening about reminding her that the sexy ER doc on TV is just trying to be me. She’s right that we are the “git’r’done” kind of docs. But what she doesn’t appreciate is that the public’s image of emergency physicians as smart, hard working under incredible pressure and yes, sexy (that’s for my wife) is partly responsible for our increased salaries.
So what about balance billing?
It’s appropriate that our compensation is scrutinized closely by us, the hospitals where we work, the insurers and the public. We should never get greedy or use our position to gouge our patients. But we should also never lose sight of the true and lasting value of what we do. It took us all a lot of hard work and intelligence to get here. All have invested heavily of time and money to be able to do what we do. We sacrifice our lives and health to do the best job possible at the worst times. And in a world of relative value, the product we produce is literally priceless. We demand a lot of money from our patients for the service that we provide. Don’t ever apologize for that. You earned it.