The movie “Looper” is driven by several individuals who are motivated by the interest of someone they love. Any reasonable person placed in their shoes would take the same steps. Unfortunately, these actions, despite the pure and rational intentions behind them, end tragically.
I fear this is the point we have reached in emergency medicine. We have long been an amalgamation of sorts — independent contractors, democratic groups, contract management groups, and hospital employees. I am one of the latter. Market factors have kept a reasonable balance among these competing entities, but some of these factions, acting in their own best interests, may now be jeopardizing the profession we love.
Capitalism. Democracy. Freedom. These pillars of American society are unraveling our specialty at the cost of what built it — the patient and the clinician. The commotion has grown as democratic groups, small and large, become increasingly obsolete, bought out or competed out by larger contract management groups. Complex market forces are at play, to be sure, but what is the eventual impact to emergency medicine?
Democratic groups have long been the bedrock of not only emergency medicine but medicine at large. Positions in these groups have traditionally been among the highest paid, most desired and have increased autonomy. Why, if democratic groups are so lucrative, are they selling out and losing contracts to contract management groups with accelerating frequency? The reasons are multifactorial in today's changing health care environment. Many influences besides money create incentives for individuals in a group to sell — nearing retirement, burnout, job and contract insecurity, negotiating power, administrative fatigue, and ease of practice. Or sometimes they just want to be the first one off the sinking ship. These reasonable motives may be best for the individual and the group, but they may drown our specialty.
What of contract management groups? Some claim to be majority physician-owned and -controlled, which sounds good. Having physicians as high-level executives, however, may be a semantic technicality that is a better recruiting tool than a true indication of equitable ownership to the frontline working doc. Like Animal Farm, some physicians are more equal than others. Nevertheless, the current aim of these large groups seems to be growth, which is financially shrewd because larger scale improves negotiating power with the equally consolidated insurance companies and hospital groups: Fighting fire with fire, so to speak; eat or be eaten.
Growth comes at a cost, however. Cash is required to buy out groups, offer hospitals enticing contracts, and recruit physicians. This capital comes from investment firms taking stake in many of the contract management groups. It makes for strange bedfellows to invite those who see right and wrong as profit and loss into the sacred realm of medicine. These “rainmakers” do not care about the Hippocratic Oath, doctor-patient relationship, or individual physician but the bottom line: return on investment. As these contract management groups grow in scale, so does their profitability, not just in the ability to streamline aggressive billing and negotiate with hospitals or insurance companies, but also to improve productivity through thinner staffing and cost controls through their biggest expenditure — physician salaries.
Increasing use of midlevel providers will improve the bottom line at the potential detriment to patient care and decrease physician demand, further lowering salaries. As health care expenditure grows unsustainably, adding more middlemen between the patient and the physician, especially profit-hungry ones, would seem a poor strategy to control cost. As these contract management groups and their financial backers obtain a critical mass of market share, first locally, then nationally, they will become the primary set point of our salaries and our future.
Competition breeds success, and perhaps contract management groups are simply the victors collecting their spoils. Monopolies work, in board games and in life, but they disproportionately favor the few at the expense of the many. Competition among democratic groups with each other and with other entities encourages fair compensation to the individual physician. As competition falters and the market share of democratic groups shrinks, so too will the salaries of the working clinician. Few of us went into emergency medicine for the money, but naïveté about its influence is dangerous.
As salaries fall in comparison with other specialties, so will the competitiveness of our residency applicants. And what of the patient? Traditionally, hospitals or individual physicians could simply look for another option to ensure patients receive optimal care if a democratic or contract management group fell short of expectations. What choice will there be when all of emergency medicine is managed by three groups? Or two? Or one? Contract management groups in and of themselves are not evil, nor are democratic groups inherently noble, but we all benefit from choice in the marketplace regardless of practice type or location. Progressive loss of this competition through corporate consolidation will, in the long run, be a detriment to the practicing physician and the patient.
Medicine is certainly a business, and that is truer today than ever. I understand from a business standpoint why democratic groups are selling out, why hospitals are changing contracts, and why contract management groups are expanding. It would seem wise to do that if I were in their shoes, but at what eventual cost to emergency medicine? How is disaster averted in “Looper?” One individual makes the ultimate sacrifice for society to survive. Whether choosing that next job or holding that next shareholder vote, maybe the time has come for some of us to do the same.
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