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  • #61
    Originally posted by ENT Doc View Post

    That’s nuts. This is what happens when national organizations don’t examine workforce needs on an ongoing basis and when the ACGME doesn’t assess these issues before approving of more residency slots.
    Unfortunately, the big CMGs are interwoven in the main national organization, ACEP. Many of the new residencies being opened are being opened by HCA which owns Envision (who used to be EmCare but they change their name every 5 years or so when the old name gets bad enough of a reputation). They open residencies and get to profit off cheap labor and then get to flood the market with labor lowering their costs even more. Some of the main sites only see 20k-30k a year which is not even close enough to being able to support a proper residency. It should publicly be called criminal if anyone in ACEP had any balls/ovaries. The new program directors either don't care and/or are completely unaware. There's a somewhat prominent EM guy on Twitter with 50k followers or so (I'm not even sure why he has so many followers) that will be the new program director of a new residency that he has been working on getting accredited. There's a few commenting about the oversaturation and future of EM but the vast majority are EM folks and are congratulating him, etc. This specialty is going to get what it deserves in the end, I'm afraid. I'm far enough along and in a current position that I'm going to be more than fine but current residents are going to be in for some bad news.

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    • #62
      Originally posted by CordMcNally View Post

      Unfortunately, the big CMGs are interwoven in the main national organization, ACEP. Many of the new residencies being opened are being opened by HCA which owns Envision (who used to be EmCare but they change their name every 5 years or so when the old name gets bad enough of a reputation). They open residencies and get to profit off cheap labor and then get to flood the market with labor lowering their costs even more. Some of the main sites only see 20k-30k a year which is not even close enough to being able to support a proper residency. It should publicly be called criminal if anyone in ACEP had any balls/ovaries. The new program directors either don't care and/or are completely unaware. There's a somewhat prominent EM guy on Twitter with 50k followers or so (I'm not even sure why he has so many followers) that will be the new program director of a new residency that he has been working on getting accredited. There's a few commenting about the oversaturation and future of EM but the vast majority are EM folks and are congratulating him, etc. This specialty is going to get what it deserves in the end, I'm afraid. I'm far enough along and in a current position that I'm going to be more than fine but current residents are going to be in for some bad news.
      Sad. I took at look at the # of trainees in the ENT pipeline based on the ACGME data. Over the last 20 years we've had a 29% decline in the US population per each trainee. And that doesn't even take into account the effect of APPs. We may be suffering the same fate, albeit at a slower rate.

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      • #63
        Originally posted by ENT Doc View Post

        Sad. I took at look at the # of trainees in the ENT pipeline based on the ACGME data. Over the last 20 years we've had a 29% decline in the US population per each trainee. And that doesn't even take into account the effect of APPs. We may be suffering the same fate, albeit at a slower rate.
        I think every specialty is going to be at risk, even the surgical specialties. HCA is already opening dermatology residencies and I don't see any reason why they'll stop there. They have every incentive too open residencies, especially if the ACGME can't grow a spine and keep these groups out of resident education.

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        • #64
          Originally posted by CordMcNally View Post

          I think every specialty is going to be at risk, even the surgical specialties. HCA is already opening dermatology residencies and I don't see any reason why they'll stop there. They have every incentive too open residencies, especially if the ACGME can't grow a spine and keep these groups out of resident education.
          Queue one of my first posts about doctors needing to be afraid. We think there's this massive gap of doctor shortage but fail to account for these issues and tech.

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          • #65
            Originally posted by ENT Doc View Post

            Queue one of my first posts about doctors needing to be afraid. We think there's this massive gap of doctor shortage but fail to account for these issues and tech.
            I like to compare it to the farming industry. 100 years ago nobody would have believed you that we'd be able to feed 8 billion people on even less farm land and a significantly less amount of people involved in farming. They would have thought we'd need everyone to be a farmer to support our current production.

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            • #66
              Originally posted by CordMcNally View Post

              I like to compare it to the farming industry. 100 years ago nobody would have believed you that we'd be able to feed 8 billion people on even less farm land and a significantly less amount of people involved in farming. They would have thought we'd need everyone to be a farmer to support our current production.
              Agreed. But I think the limit in healthcare is not the amount of work — as more treatments become available, people live longer, baby boomers get older, and obesity increases, the amount of work and complexity will continue to increase. The problem is that the amount of money that’s available to pay for the ever increasing healthcare work is finite.

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              • #67
                Other issues I see in EM

                1. Massive use of physician extenders which dramatically decreases the need for physicians. The existing physicians get to make some money off these extenders.

                2. Many private insurance companies now playing Monday morning quarterback and denying ER visits because they felt the symptoms did not warrant an ER visit. United Healthcare has already started to implement it and others will soon follow. Now you will see patients being billed for what they thought their insurance will cover and not being able to pay the charges but more importantly not seeking EM care because of the fear of being struck with a costly expense. ER cannot survive on Medicaid and Medicare alone.

                I see less need for ER physicians and there will be a decrease in salary / income.

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                • #68
                  Originally posted by Kamban View Post
                  Other issues I see in EM

                  1. Massive use of physician extenders which dramatically decreases the need for physicians. The existing physicians get to make some money off these extenders.

                  2. Many private insurance companies now playing Monday morning quarterback and denying ER visits because they felt the symptoms did not warrant an ER visit. United Healthcare has already started to implement it and others will soon follow. Now you will see patients being billed for what they thought their insurance will cover and not being able to pay the charges but more importantly not seeking EM care because of the fear of being struck with a costly expense. ER cannot survive on Medicaid and Medicare alone.

                  I see less need for ER physicians and there will be a decrease in salary / income.
                  As well as just a generalized push for people to stop going to the ED for a ton of the stuff they currently go to the ED for. I'm not sure the stats but just like how a ton of our imaging isn't indicated, I'm sure a ton of ED visits aren't either. As big healthcare data becomes a bigger and bigger thing, insurers will obviously push to eliminate these unnecessary visits.

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                  • #69
                    Originally posted by Panscan View Post

                    As well as just a generalized push for people to stop going to the ED for a ton of the stuff they currently go to the ED for. I'm not sure the stats but just like how a ton of our imaging isn't indicated, I'm sure a ton of ED visits aren't either. As big healthcare data becomes a bigger and bigger thing, insurers will obviously push to eliminate these unnecessary visits.
                    That is what United Healthcare is saying to prevent unnecessary ER visits. Is that substernal burning /indigestion really GERD or an inferior wall ischemia / MI So the patient will proactively postpone the visit and seek urgent care ( which is starting to become expensive too) or wait until Monday to see his FP. Most will survive but there might be more deaths or late visits to ER with full blown MI and cardiac arrest. The big insurers will make more profits.

                    The Medicaid patients will somehow not stop using the ER as their family doc visit and the homeless drug OD will still make those countless visits but those will not bring in much income.

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                    • #70
                      Ever since it was an “emergency room”, they tried to figure out a way to keep them from coming. Then they needed 2 rooms, then 4, ….then 54. Even during covid, our area demonstrated that the offices and outpatient centers couldn’t handle the volume of patients, so the community steered them all to us with our urging, mid pandemic, and things started going smoothly. Well patients, sick patents, and even just rapid testing for large groups. The ED here was the only place you could get the patients processed quickly, efficiently, and accurately. Worked really well. Rich and poor, given the choice they choose to come to our shop pretty often.

                      Our radiologists don’t complain about imaging, they ask us to please do more, and keep adding services. But that’s the difference between private practice and academic places.

                      The big, well known, resident run university center down the road went from a typical disaster zone, to a super disaster zone during the same time.

                      I’ve always thought it’s backwards. You set up the ED to run well, with strong systems in places, and then steer the patents toward it. Provide great service to the private community docs, and the patients. Trying to do the opposite has never worked well. But of course, I’m biased.

                      I agree though, the specialty is being squeezed by insurance companies on one side, hedge fund profiteers on the other, and the talent pool is being diluted down at the same time. And It’s going to get worse before it gets better.
                      Last edited by Jaqen Haghar MD; 06-21-2021, 09:49 AM.

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                      • #71
                        Originally posted by Dusn View Post

                        Agreed. But I think the limit in healthcare is not the amount of work — as more treatments become available, people live longer, baby boomers get older, and obesity increases, the amount of work and complexity will continue to increase. The problem is that the amount of money that’s available to pay for the ever increasing healthcare work is finite.
                        You must not read the headlines these days. Money being finite is a myth.

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                        • #72
                          Oops. Duplicate…

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                          • #73
                            Originally posted by Panscan View Post

                            As well as just a generalized push for people to stop going to the ED for a ton of the stuff they currently go to the ED for. I'm not sure the stats but just like how a ton of our imaging isn't indicated, I'm sure a ton of ED visits aren't either. As big healthcare data becomes a bigger and bigger thing, insurers will obviously push to eliminate these unnecessary visits.
                            This is already happening. Employers are starting to 'punish' ER abusers via medical plan design benefit differential. And isn't this a good thing, generally? Pushing people to centers of treatment optimized to handle the complaint/issue? I guess it depends on who's answering the question: the premium-paying population, the ER doc, the hospital conglomerate may have opposing thoughts.

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                            • #74
                              Originally posted by Jaqen Haghar MD View Post
                              Ever since it was an “emergency room”, they tried to figure out a way to keep them from coming. Then they needed 2 rooms, then 4, ….then 54. Even during covid, our area demonstrated that the offices and outpatient centers couldn’t handle the volume of patients, so the community steered them all to us with our urging, mid pandemic, and things started going smoothly. Well patients, sick patents, and even just rapid testing for large groups. The ED here was the only place you could get the patients processed quickly, efficiently, and accurately. Worked really well. Rich and poor, given the choice they choose to come to our shop pretty often.

                              Our radiologists don’t complain about imaging, they ask us to please do more, and keep adding services. But that’s the difference between private practice and academic places.

                              The big, well known, resident run university center down the road went from a typical disaster zone, to a super disaster zone during the same time.

                              I’ve always thought it’s backwards. You set up the ED to run well, with strong systems in places, and then steer the patents toward it. Provide great service to the private community docs, and the patients. Trying to do the opposite has never worked well. But of course, I’m biased.

                              I agree though, the specialty is being squeezed by insurance companies on one side, hedge fund profiteers on the other, and the talent pool is being diluted down at the same time. And It’s going to get worse before it gets better.
                              Why should you have to steer patients towards an ED ? I think a lot of people know what is an emergency and what isn’t. The real ones aren’t going to need convincing.

                              reality is a ton of ED volume could be handled at by PCP or various specialists in their offices. In the short term it rewarded EM but will go away and long term punish EM due to proliferation of docs and reduced demand. Very similar to how radiologists love increased volume which is a very short sided outlook and inevitably decreases reimbursement per study

                              Comment


                              • #75
                                Originally posted by Kamban View Post
                                Other issues I see in EM

                                1. Massive use of physician extenders which dramatically decreases the need for physicians. The existing physicians get to make some money off these extenders.

                                2. Many private insurance companies now playing Monday morning quarterback and denying ER visits because they felt the symptoms did not warrant an ER visit. United Healthcare has already started to implement it and others will soon follow. Now you will see patients being billed for what they thought their insurance will cover and not being able to pay the charges but more importantly not seeking EM care because of the fear of being struck with a costly expense. ER cannot survive on Medicaid and Medicare alone.

                                I see less need for ER physicians and there will be a decrease in salary / income.
                                About 20% of the EM physicians I interact with shouldn’t be EM physicians. So maybe the herd needs culling.

                                Comment

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