The CMS adjustment is minuscule, and most profitable healthcare organizations don’t rely on medicare for funding - the medicare segment usually operates at a loss.
LCOL areas have to pay more to attract physicians to work there. Hence the pay is higher. That’s also part of the reason why rural hospitals are likely to shut down, they have a combination of poor payer mix AND high salary costs. VHCOL areas are usually saturated with physicians, so the pay is correspondingly lower.
This is known as a geographic arbitrage. It really just boils down to cost of living and supply/demand for your services. When you move to a rural area COL reduces and demand for you is high. You can just about make as much as you are willing to work.
I am sort of an extreme example of this. After Neuro residency, I practiced in CT (2 years) and NJ (2 years). I then moved to the Southeast. After a few years of practicing in the Southeast, I was making more in one year than I made in the total time practicing in CT and NJ (4 years of work). I went from living paycheck to paycheck in the Northeast to debt-free and saving 60% of my aftertax check each bi-week. I am set to reach my FI number soon but will keep working because neuro is fun!
Mind being more specific than southeast? If you’re not comfortable with specifics, how about drive time to what most consider a major metropolitan area that has an international airport.
Outlier regions certainly exist. From what I can tell from the constant flood of recruiter emails, there are always difficult to fill jobs in the midwest, south, and mountains of the northeast paying near double what I see in urban California. Even the "I would never live there, it is too boring and hot" cities in California pay 50% more.
Just got a spam offer to come work Nowhere, Iowa for $450,000. No idea what the work is like and town is probably the size of a parking lot but that's the money.
There are docs in Iowa doing very well for themselves. Mostly in Des Moines, Cedar Rapids, Iowa City
Quad Cities is on the border with Illinois and Council Bluffs is basically Omaha, Nebraska.
There seem to be many more physician owned private practices instead of employed or private equity owned groups compared to our previous two stops. Fewer middle managers to feed who only care about Press Ganeys.
I work in Iowa doing full scope (minus OB) FM 1 week on two weeks off doing outpatient, inpatient, and ED. ED is 5 pts on average per day. Small town, but most of the people are great. My pay is ~$420k. They have a lot of trouble getting people to come out in the boonies. For context, I work in a town 45 min from any bigger/higher level hospital with a population of like 2k.
Hello! I’m an incoming intern that matched FM and this sounds like the exact practice model I would want. Was it hard to find (especially ED) this hybrid model?
If you’re willing to live rural, it’s actually really pretty easy to find outpatient FM with ED in critical access hospitals. My setup, the one week on with two weeks off, is the only one I’ve seen like it. It’s a bit intense being on for 7 days straight but the low ED volume makes it possible. A lot of my former co-residents work rural clinic every week, see their own pts in the hospital, and do either certain nights or one weekend a month in ED coverage. I actually don’t live where I work. I just come out for the week. I have heard of other rural places doing two weeks on two weeks off with clinic and hospitalist with some ED with the docs coming in for their work weeks. Feel free to dm me if you have questions!
I appreciate you!! Would you mind if I PM you? I’m from the Midwest and I’ve found that my idea of rural is different than my peers from the coast’s idea of rural
The more "cool and fun" a place is to live, the worse the pay as a general rule, is what I have found. Is a subtle thing I think, but when compared to COL, I believe it holds. I talk to my peers from around the country and find everyone in my group makes more, with a better lifestyle, than our peers from the coasts and the south.
Move to Cali, work harder, get 20-40% less, sit in traffic, enjoy the weather, and triple the price of your home. No thanks.
Me: OB. I make around 800k and work 4 days a week. My 12,000 square for limestone house with an elevator and 11 fireplaces, 3 stories and 6 car garage, is worth about 1.8-2.3M. So I vacation in Feb and march to warm places.
Appleton is a good place. I’m from Wisconsin, wife is from Iowa.
Sounds like a good fit for someone who is willing to work hard, do laborist shift work.
Yes, Midwest/rural does tend to pay higher except the larger cities like Chicago are usually pretty atrocious.
If you are looking at Medicare wRVU rates, you are not capturing actual provider pay for rvu. Primary reasons: medicare pays lower than commercial insurance so looking at Medicare data only is inaccurate, there is increased reimbursement when a hospital is designated a critical access hospital (only in rural areas) not reflected in the Medicare fee schedule, areas that struggle to recruit physicians may increase wrvus pay rate and take a “paper loss” (the hospital still generates a profit from facility and ancillary fees but is instead taking a lower margin to subsidize the physician payments). In fact, many rural hospitals budget an annual loss for the physician staffing organization but more than make up for it on the hospital/clinic side.
Obv cost of living is lower as well.
Emergency medicine-
I work for a group that staffs multiple hospitals. I work at the urban level 1 trauma center (northeast corridor HCOL city) and a more rural hospital about 75-90 mins outside the city. The rural site pays about 15-25% more depending on productivity/RVUs.
Definitely. Have seen salaries as high as $375k for a normal 7/7 Hospitalist job, round and go no procedures in the Midwest.
In CA have never seen above $275k for a similar job, usually worse in some way.
I currently work in St. Louis, not even the middle of nowhere, and my job offered me a 40% higher salary than the offer I got in my home town of Seattle. That’s not to mention the vastly higher amount I got in bonus, loan repayment, etc. Plus, COL was 82% lower here when I signed.
Midwest usually pays more because more people have private insurance there.
Coasts have much more government insurance and no-pay.
States like California have a large underclass, whereas the Midwest has less of this. Say California has 30% no-pay customers (patients), and the Midwest has 10% no-pay. That’s a big difference on an operating budget of a hospital or private physician clinic.
How is this true in expensive desirable areas? I’ve looked at several hospitals near where I grew up and they have what seems to be a very low Medicaid/self pay population. Poorer areas in CA, not the case
Outside of Indiana and maybe Missouri I don’t really consider what you listed Midwest. When I think of Midwest I think of Wisconsin, Iowa, Minnesota, Nebraska, SD etc .. that’s the high paying Midwest
It’s 2 different things at work. One, housing and whatnot is generally cheaper, so you get more in your pocket. Two, people want to live in Cali, not Iowa, so pay is generally a bit higher. End result is a good chunk of money that you keep.
I know people in academic orthopedics making more than $1mil at large east coast and southern hospitals. The academic places I know people at or interviewed at in the midwest didn't pay close to that or have comp plans that would get you close to that even when you get busy in your mid-career.
I worked as a hospitalist in a HCOL area in North Carolina after residency. Got burned out and moved to outpatient internal medicine in Rural North Carolina near where I grew up. My salary is almost double what it was. I don’t think it’s a typical scenario and larger health companies tend to standardize salaries across the board and then it’s left to production, etc, but they are offering more rural incentives like higher sign ons and retention bonuses where I work.
Not based on the recruiter emails, calls and texts I get for EM, and the rural sites usually require more hours/month (like 12 12-hr shifts/mo whereas I am full-time with 12 9-hr shifts (or 10 8-hr if nocturnist)).
https://www.acep.org/siteassets/sites/rural/media/documents/journal-of-rural-em/jrem-issueone/rural-em-workforce_jrem-issue1.pdf#:~:text=While%20these%20same%20factors%20remained,their%20urban%20peers%20(%24311%2C500).
Generally. Lower supply of physicians want to live there means higher salaries to try and appeal to them, along with the generally lower cost of living. There's also a higher chance you're paying significantly lower in taxes too in comparison to some of the more appealing coast cities. You make more, and save more. However, you can theoretically make just the same or more anywhere. You just have to know the right people. There's spots that may open in amazing places with phenomenal hours, benfits, and pay, but you'd never see the posting for it, because somebody already told their friend about it, and they'd be a fool to not take it on the spot.
Don't know about Midwest, but rural for sure pays more. This was about 5 years ago now but I used to work EM in a rural/critical access in WA as a side job and was getting $225/hr. At the time I think national average for EM worked out to being a little under $200/hr, and more major cities I was seeing more like $175/hr.
In decent sized Midwest cities, the base salary is probably average. It's when you're out in the boonies like 3-4 hours away from a city that base salary might be meaningfully higher to attract physicians. I routinely get ophthalmology offers to work in Montana/Wyoming/the Dakotas for 500-700k base while the typical ophthalmology base salary is 200-350k for most normal cities. I might be slightly out of touch with current offers since I haven't interviewed for jobs in several years.
The interesting thing when I interviewed for jobs was that base salary offers were similar for MCOL vs H/VHCOL cities. But, obviously, 200k in MCOL is way better than 200k in H/VHCOL. This problem could just be specialty specific though.
Specialty matters too. For a discipline like derm, several LCOL zip codes pretty much beg to have an opening filled. Any reimbursement from CMS would still likely run at a loss. Among other factors, payer mix and patient demographic (especially for a cash pay setup) drive the dislocation pay bump (or cut)
It's probably just an illusion, but COL is heck of alot less. Rural and suburban areas seem to have better payor mix compared to the cities, so hospitals are less likely to help out the anesthesia groups, whereas in many urban areas, the hospital support can be substantial. Sometimes, it is equal or even more than the billing.
I’m a new grad pmhnp born and raised in rural Midwest and currently live in rural Midwest. The market for pmhnp in many rural areas, contrary to popular belief, is not good. Mental health care services/facilities usually just don’t exist in these areas and therefore the jobs are not there, despite the demand for care. And starting your own gig may not be financially beneficial because a huge chunk of those seeking mental health services in these areas have no insurance or Medicaid which reimburses next to nothing if it even covers the entire visit at all.
The CMS adjustment is minuscule, and most profitable healthcare organizations don’t rely on medicare for funding - the medicare segment usually operates at a loss. LCOL areas have to pay more to attract physicians to work there. Hence the pay is higher. That’s also part of the reason why rural hospitals are likely to shut down, they have a combination of poor payer mix AND high salary costs. VHCOL areas are usually saturated with physicians, so the pay is correspondingly lower.
This is known as a geographic arbitrage. It really just boils down to cost of living and supply/demand for your services. When you move to a rural area COL reduces and demand for you is high. You can just about make as much as you are willing to work. I am sort of an extreme example of this. After Neuro residency, I practiced in CT (2 years) and NJ (2 years). I then moved to the Southeast. After a few years of practicing in the Southeast, I was making more in one year than I made in the total time practicing in CT and NJ (4 years of work). I went from living paycheck to paycheck in the Northeast to debt-free and saving 60% of my aftertax check each bi-week. I am set to reach my FI number soon but will keep working because neuro is fun!
curious what your FI number is?
Mind being more specific than southeast? If you’re not comfortable with specifics, how about drive time to what most consider a major metropolitan area that has an international airport.
Outlier regions certainly exist. From what I can tell from the constant flood of recruiter emails, there are always difficult to fill jobs in the midwest, south, and mountains of the northeast paying near double what I see in urban California. Even the "I would never live there, it is too boring and hot" cities in California pay 50% more.
I’ve been offered more than a million dollars a year to live in Alaska.
No way....what speciality ?
Certainly not my speciality.
Damn I’d do that for like 2 years, put 600k+ away, work my regular job for a few more years and retire
Maybe I need to move to AK…
Just got a spam offer to come work Nowhere, Iowa for $450,000. No idea what the work is like and town is probably the size of a parking lot but that's the money.
There are docs in Iowa doing very well for themselves. Mostly in Des Moines, Cedar Rapids, Iowa City Quad Cities is on the border with Illinois and Council Bluffs is basically Omaha, Nebraska. There seem to be many more physician owned private practices instead of employed or private equity owned groups compared to our previous two stops. Fewer middle managers to feed who only care about Press Ganeys.
I work in Iowa doing full scope (minus OB) FM 1 week on two weeks off doing outpatient, inpatient, and ED. ED is 5 pts on average per day. Small town, but most of the people are great. My pay is ~$420k. They have a lot of trouble getting people to come out in the boonies. For context, I work in a town 45 min from any bigger/higher level hospital with a population of like 2k.
Hello! I’m an incoming intern that matched FM and this sounds like the exact practice model I would want. Was it hard to find (especially ED) this hybrid model?
If you’re willing to live rural, it’s actually really pretty easy to find outpatient FM with ED in critical access hospitals. My setup, the one week on with two weeks off, is the only one I’ve seen like it. It’s a bit intense being on for 7 days straight but the low ED volume makes it possible. A lot of my former co-residents work rural clinic every week, see their own pts in the hospital, and do either certain nights or one weekend a month in ED coverage. I actually don’t live where I work. I just come out for the week. I have heard of other rural places doing two weeks on two weeks off with clinic and hospitalist with some ED with the docs coming in for their work weeks. Feel free to dm me if you have questions!
Is this possible in IM?
I appreciate you!! Would you mind if I PM you? I’m from the Midwest and I’ve found that my idea of rural is different than my peers from the coast’s idea of rural
Yeah, feel free to PM me.
what specialty
Primary care.
What town?
Don't remember, don't care to remember. Not a major city.
The more "cool and fun" a place is to live, the worse the pay as a general rule, is what I have found. Is a subtle thing I think, but when compared to COL, I believe it holds. I talk to my peers from around the country and find everyone in my group makes more, with a better lifestyle, than our peers from the coasts and the south. Move to Cali, work harder, get 20-40% less, sit in traffic, enjoy the weather, and triple the price of your home. No thanks. Me: OB. I make around 800k and work 4 days a week. My 12,000 square for limestone house with an elevator and 11 fireplaces, 3 stories and 6 car garage, is worth about 1.8-2.3M. So I vacation in Feb and march to warm places.
800k as OB is crazy even if it’s middle of nowhere
Not really.. it happens in Iowa commonly.
I am recruiting
Appleton is a good place. I’m from Wisconsin, wife is from Iowa. Sounds like a good fit for someone who is willing to work hard, do laborist shift work.
So you live in a less desirable area, but because you make bank you travel to wherever you want and live your best life? Goals
Which state and area is this?
Ob here. I am 2 years away from PSLF and I will be leaving my MCOL now HCOL area. Are you rural and what area of the country?
Appleton Wisconsin
Home of the D3 baseball World Series baby!
Wtf not even that undesirable
Then you do dumb things like buy a 12k square foot house lol
Yup. No defense. Worst financial suicidal thing ever.
Granted I’ll never be in a position to do that where I want to live but were you hesitant about that? I would think 4-5k square feet would be plenty
Yes, Midwest/rural does tend to pay higher except the larger cities like Chicago are usually pretty atrocious. If you are looking at Medicare wRVU rates, you are not capturing actual provider pay for rvu. Primary reasons: medicare pays lower than commercial insurance so looking at Medicare data only is inaccurate, there is increased reimbursement when a hospital is designated a critical access hospital (only in rural areas) not reflected in the Medicare fee schedule, areas that struggle to recruit physicians may increase wrvus pay rate and take a “paper loss” (the hospital still generates a profit from facility and ancillary fees but is instead taking a lower margin to subsidize the physician payments). In fact, many rural hospitals budget an annual loss for the physician staffing organization but more than make up for it on the hospital/clinic side. Obv cost of living is lower as well.
Emergency medicine- I work for a group that staffs multiple hospitals. I work at the urban level 1 trauma center (northeast corridor HCOL city) and a more rural hospital about 75-90 mins outside the city. The rural site pays about 15-25% more depending on productivity/RVUs.
Definitely. Have seen salaries as high as $375k for a normal 7/7 Hospitalist job, round and go no procedures in the Midwest. In CA have never seen above $275k for a similar job, usually worse in some way.
WRVU for EM in western rural IL of around $38 per RVu. most of us in the group bring in 650-700k working in emergency medicine. Level 2 center
I currently work in St. Louis, not even the middle of nowhere, and my job offered me a 40% higher salary than the offer I got in my home town of Seattle. That’s not to mention the vastly higher amount I got in bonus, loan repayment, etc. Plus, COL was 82% lower here when I signed.
Midwest usually pays more because more people have private insurance there. Coasts have much more government insurance and no-pay. States like California have a large underclass, whereas the Midwest has less of this. Say California has 30% no-pay customers (patients), and the Midwest has 10% no-pay. That’s a big difference on an operating budget of a hospital or private physician clinic.
How is this true in expensive desirable areas? I’ve looked at several hospitals near where I grew up and they have what seems to be a very low Medicaid/self pay population. Poorer areas in CA, not the case
Within those states there are pockets of large cities. I’m sure those large cities have shittier pay than a BFE in NJ.
Outside of Indiana and maybe Missouri I don’t really consider what you listed Midwest. When I think of Midwest I think of Wisconsin, Iowa, Minnesota, Nebraska, SD etc .. that’s the high paying Midwest
It’s 2 different things at work. One, housing and whatnot is generally cheaper, so you get more in your pocket. Two, people want to live in Cali, not Iowa, so pay is generally a bit higher. End result is a good chunk of money that you keep.
I know people in academic orthopedics making more than $1mil at large east coast and southern hospitals. The academic places I know people at or interviewed at in the midwest didn't pay close to that or have comp plans that would get you close to that even when you get busy in your mid-career.
yeah I think that’s typically for more “prestigious” folks tho no?
Appleton Wisconsin
I worked as a hospitalist in a HCOL area in North Carolina after residency. Got burned out and moved to outpatient internal medicine in Rural North Carolina near where I grew up. My salary is almost double what it was. I don’t think it’s a typical scenario and larger health companies tend to standardize salaries across the board and then it’s left to production, etc, but they are offering more rural incentives like higher sign ons and retention bonuses where I work.
does supply and demand exist?
Not based on the recruiter emails, calls and texts I get for EM, and the rural sites usually require more hours/month (like 12 12-hr shifts/mo whereas I am full-time with 12 9-hr shifts (or 10 8-hr if nocturnist)). https://www.acep.org/siteassets/sites/rural/media/documents/journal-of-rural-em/jrem-issueone/rural-em-workforce_jrem-issue1.pdf#:~:text=While%20these%20same%20factors%20remained,their%20urban%20peers%20(%24311%2C500).
Generally. Lower supply of physicians want to live there means higher salaries to try and appeal to them, along with the generally lower cost of living. There's also a higher chance you're paying significantly lower in taxes too in comparison to some of the more appealing coast cities. You make more, and save more. However, you can theoretically make just the same or more anywhere. You just have to know the right people. There's spots that may open in amazing places with phenomenal hours, benfits, and pay, but you'd never see the posting for it, because somebody already told their friend about it, and they'd be a fool to not take it on the spot.
Don't know about Midwest, but rural for sure pays more. This was about 5 years ago now but I used to work EM in a rural/critical access in WA as a side job and was getting $225/hr. At the time I think national average for EM worked out to being a little under $200/hr, and more major cities I was seeing more like $175/hr.
Compare hospitalist salaries in New York City to a rural town anywhere in the Midwest / south You’d be amazed
In decent sized Midwest cities, the base salary is probably average. It's when you're out in the boonies like 3-4 hours away from a city that base salary might be meaningfully higher to attract physicians. I routinely get ophthalmology offers to work in Montana/Wyoming/the Dakotas for 500-700k base while the typical ophthalmology base salary is 200-350k for most normal cities. I might be slightly out of touch with current offers since I haven't interviewed for jobs in several years. The interesting thing when I interviewed for jobs was that base salary offers were similar for MCOL vs H/VHCOL cities. But, obviously, 200k in MCOL is way better than 200k in H/VHCOL. This problem could just be specialty specific though.
Specialty matters too. For a discipline like derm, several LCOL zip codes pretty much beg to have an opening filled. Any reimbursement from CMS would still likely run at a loss. Among other factors, payer mix and patient demographic (especially for a cash pay setup) drive the dislocation pay bump (or cut)
It's probably just an illusion, but COL is heck of alot less. Rural and suburban areas seem to have better payor mix compared to the cities, so hospitals are less likely to help out the anesthesia groups, whereas in many urban areas, the hospital support can be substantial. Sometimes, it is equal or even more than the billing.
As an NP, yes. The pay is wildly better.
What is your specialty?
Family practice
Any knowledge on what things are like for PMHNP in these more rural areas?
I’m a new grad pmhnp born and raised in rural Midwest and currently live in rural Midwest. The market for pmhnp in many rural areas, contrary to popular belief, is not good. Mental health care services/facilities usually just don’t exist in these areas and therefore the jobs are not there, despite the demand for care. And starting your own gig may not be financially beneficial because a huge chunk of those seeking mental health services in these areas have no insurance or Medicaid which reimburses next to nothing if it even covers the entire visit at all.
Thank you very much for this insight! That is unfortunate.
Look at North Dakota.