BY RUTH SORELLE, MPH
The lightning-swift switch in emergency department physician staffing at Summa Health System in Akron, OH, turned out to be the final straw for the hospital's board of directors. What started with the emergency physician group being replaced on Jan. 1 ended only 25 days later with the Summa board of directors accepting the resignation of Thomas Malone, MD, the controversial president and CEO whose actions sparked the turmoil.
Those involved in the dispute between the Summa Health System and the emergency medicine group, Summa Emergency Associates (SEA) that staffed its emergency departments for 40 years, agreed on one thing: At midnight on New Year's Eve, the system's contract with SEA ended and one hastily written and approved with US Acute Care Solutions (USACS) was activated.
"The night of the transition, they [physicians from USACS] came in an hour early," said Jeffrey Wright, MD, the president of SEA. "We had all the patients taken care of, and we did an appropriate checkout. They took over the new patients at 11:15 p.m. We checked out, and our doctors left at midnight. Dr. Malone walked us out."
Prior to Dr. Malone's resignation, nearly 250 doctors had voted no confidence in the administration as had the 230 residents in its well-respected residency programs.
Letters from the American College of Emergency Physicians, the American Academy of Emergency Medicine, the Society of Academic Emergency Medicine, and the Emergency Medicine Residents Association all pointed to the need for careful consideration in selecting a leader of the residency program and its faculty. "USACS must also commit itself to the preservation of the academic missions, including the Emergency Medicine residency program, at the Summa Health System Hospitals," SAEM wrote in its statement. "High-stakes negotiations take time, effort, and ultimately, compromise. All stakeholders, including the public, payers, health care administrators, and physicians, must recognize the danger this failed negotiation represents to Emergency Medicine, and ultimately, to the care of critically ill and injured patients. SAEM fully stands with and supports those who have dedicated their academic careers to our specialty as well as the residents and fellows who have trusted Summa Health to provide them with the high-quality training they expected."
There is no question that negotiations between Dr. Malone and Dr. Wright began late. The three-year contract that Summa Health and Summa Emergency Associates operated under until Dec. 31 came about as a request for proposal issued in 2013, said Dr. Wright. To win the contract, his group had to agree to staff emergency departments at the Akron and Barberton campuses, and at Wadsworth-Rittman, Summa Health Green, and Summa Health Medina. Negotiations began in the summer, he said. Only the first two emergency departments were profitable for the group, and SEA told the administration that the hospital had to subsidize operations at the other three facilities for the physician group to avoid a huge financial loss.
Dr. Wright said Dr. Malone put him off when he asked about the contract renewal before late November. "We were offered the first contract in this negotiation on Nov. 28," he said. He said he discussed it briefly with Valerie Gibson, RN, the system's chief operating officer. "That first contract cut GME funding by 20 percent, which took it from 10 core faculty down to five," Dr. Wright said.
Dr Thomas Malone
That would not meet the requirements of the Accreditation Council for Graduate Medical Education, he said, because the program's 30 residents required 10 faculty members. His rewrite contained a request for a 15-year contract.
"I didn't expect to see it. However, the first contract did not address the low patient volume at the low-performing hospitals," Dr. Wright said. "One hospital sees 21 patients per day. Eighty percent of the patients are urgent care. Another hospital see 31 patients a day. Both have low acuity and volume."
That contract revision also contained a raise for the core faculty and suggested taking them out of two of the poorly performing emergency departments. He suggested making those facilities urgent care, closing them, or finding someone else to staff them. Dr. Wright said he was concerned because the contract suggested by the Summa Health leadership was worse than the one they had received three years before. During these contract negotiations, he said, Vivian von Gruenigen, MD, a senior vice president and the chief medical officer for Summa, took part in the negotiations, a fact that concerned him because she is the wife of Dominic Bagnoli, MD, the chief executive officer of USACS. "That's a major conflict of interest," said Dr. Wright.
Marty Richmond, the director of corporate communications for USACS, which is based in Canton, OH, said his understanding was that "she was peripherally involved in the negotiations with SEA. When it became obvious they would have to look for alternatives, she recused herself."
Mr. Richmond said Summa contacted USACS for the first time on Dec. 24 because he was told negotiations with SEA had stalled. "On the 27th, we were asked for a proposal," he said. "We submitted on the 29th, and by the evening of the 29th, we were told we would begin staffing [all five emergency rooms] at midnight on the first."
Mr. Richmond said USACS has a bank of Ohio physicians from which they could draw to staff the Summa EDs. "The residents were not there when we showed up" on Dec. 31, he said. "They had been sent home for the month of January." USACS officials met with the residents on Jan. 3, and the residents returned that afternoon. Scott Felten, MD, was named interim program director, and Mr. Richmond said Dr. Felten is interviewing faculty replacements. "The door is still open for the former physicians," he said. "The quickest way to continuity for the residency program is through the SEA physicians."
Sharhabeel Jwayyed, MD, the former director of the residency program, said the loss of the contract and his job "was like an ambush." He said Drs. Wright and Malone talked several times, meeting face-to-face for the first time on Dec. 26. On the 27th, he said, Dr. Malone said SEA was done.
The USACS physicians were given emergency credentials on New Year's Eve and New Year's Day. Kevin Rodgers, MD, the president of the American Academy of Emergency Medicine, said that was a red flag. He said a reasonable search for a residency director and 10 core faculty cannot be done in the five days that USACS had to fill those academic spots. The Accreditation Council for Graduate Medical Education is currently evaluating the program.
Dr. Rodgers said USACS is no longer a strictly physician-owned practice because a hedge fund is involved. USACS was established in May 2015 by Dr. Bagnoli's group, Emergency Medicine Physicians (EMP), and the investment firm of Welsh, Carson, Anderson & Stowe. "AAEM doesn't endorse that," he said.
"What is the bottom line here?" he said. "What about patients, residents and medical staff?" Dr. Rodgers asked. SEA was offered a contract extension, but Dr. Wright said he saw no advantage in that, and Dr. Rodgers agreed. "Jeff Wright looked at the offer for an extension and decided what was good for them. The contract was a bad choice and an extension would put them in a bad place," he said. He acknowledged that opinions on that differ, and said Dr. Wright and the SEA leadership were a bit complacent because of their track record with the hospital group. "There's no one not at fault here," he said.