A Florida emergency physician has filed suit against her former employers, Emergency Resources Group and Baptist Medical Center, claiming they sacrificed quality care by compensating doctors on productivity rather than the number of patients they moved through the ED.
Patricia White, DO, first began working at the Jacksonville hospital in 2005, at which point, according to the suit filed in Nassau County's Fourth Judicial Court, emergency physicians were compensated on services provided and tests ordered. In 2010, the suit claimed, the payment system was changed to a patients-per-hour basis, in which productivity bonuses were awarded for meeting patient minimums and penalties assessed for not meeting expectations.
Dr. White's attorney, Gary Baker, derided the practice as “stopwatch medicine.” “Dr. White would stay with a patient until she was sure there was nothing else she could or should do,” he said. “She's never been sued for malpractice in more than 10 years, and I believe that's because she takes the time to treat patients properly. But our belief is that Baptist and ERG just wanted to get patients in and out.”
That's hardly an uncommon approach in hospitals today, said Bon Ku, MD, an emergency physician at Thomas Jefferson University Hospital in Philadelphia. “It's pretty common practice for most emergency medicine jobs, so much so that the saying is ‘you eat what you kill.’ They reward productivity, the number of patients seen per hour. I am impressed that this doctor is going after the practice, but I think you'd be hard pressed to find an emergency medicine job that does not pay for productivity.”
Mr. Baker said he will provide evidence of cases in which Baptist's version of this policy may have harmed patients in court. In the meantime, he pointed to one case on the public record: a suit filed against Baptist by Jean Law, a nurse at the hospital, who had to have both legs below the knee and eight fingers amputated when the emergency department missed a bacterial infection that was quickly turning septic and instead sent her home with a pain prescription.
Ms. Law went to the emergency department before 5 a.m. Feb. 13, 2010, with a 104-degree fever, aches, a racing heart, and low blood pressure, according to records provided to the media by her attorneys. One of her attorneys, Eric Ragatz, called it a “textbook presentation” of sepsis, but she was sent home after doctors ruled out serious causes, and decided there was no indication of a need for antibiotics. She was sent home, and called back six hours later after results from earlier tests showed the infection.
Mr. Baker, Dr. White's attorney, said the “stopwatch” climate at Baptist likely contributed to the decision to send Ms. Law home. “With some people who were rushed in and out, we'll probably never know what happened to them, if they went someplace later on, or even died. These things fall through the cracks.”
That's possible, Dr. Ku said. “The incentive is to spend as little time with a patient as possible. I think that's perverse, and it's part of the reason why I went into academic medicine. I'm salaried, and generally in academics, we don't receive fat bonuses,” he said.
Richard M. Stromberg, MD, the president of Emergency Resources Group and the chief of emergency services for Baptist Hospitals, declined to comment on the case. “This is an active lawsuit and disagreement between a doctor and our group, and I've been forbidden to discuss it,” he said.
Baptist Health has said in a public statement that it “does not dictate how Emergency Resources Group [ERG] pays their physicians. We are committed to quality care in our emergency departments, which includes a timely visit, comprehensive care, and a positive patient experience.”
But Mr. Baker called that claim disingenuous. He pointed to a series of emails between Baptist and Dr. White's husband, Nassau County Prosecutor Wes White, that indicated that Baptist significantly influenced ERG's payment policies. “[T]he productivity thresholds for the bonus are insisted upon by Baptist Administration,” wrote ERG Administrator Paul Davidson. “If we don't comply with their wishes as good partners, there is a termination notice in our contract.
“We know from 10 years of patient satisfaction scores that the primary (if not the only) determinant of patient satisfaction scores in emergency rooms is how quickly the patients are seen,” he continued. “Inexplicably, patients and their families don't care about clinical quality, a cheery disposition, or any of the things you would normally think of in customer satisfaction. Hence the Board's insistence on speed. Hence the Board's insistence on a physician productivity bonus incentive.”
At first, Mr. Baker said, Dr. White simply lost out on her bonus. “They have a bonus pool of extra money, and you have to average about two patients per hour to qualify for that pool. If you average less than that, your bonus is smaller. Dr. White was averaging less than 1.5 patients per hour, and didn't receive any bonus.” She received no written warnings from her employers about her pace, according to Mr. Baker, but was told repeatedly to speed up.
Then, in October 2010, Dr. White was removed from Baptist's emergency department rotation entirely. Mr. Baker said the hospital's normal procedure is to assign emergency physicians a regular monthly rotation, and if days off are needed, doctors request them at the beginning of the month. “Dr. White told Baptist ahead of time that she needed the first and last day of October off to see her elderly parents,” he said. “They just didn't schedule her for the whole month. They're claiming it's just a misunderstanding, but we have a copy of the email she sent.”
Although she was never technically fired, Dr. White was never put back on the schedule, and for the past 14 months has been volunteering her services in charity facilities. “When you're taken off shift from the emergency room, it sends a message to the rest of the field that something must be wrong with you,” Mr. Baker said. “It has damaged her reputation in the medical community, so she's not finding employment in other ERs.”
Dr. White's five-count lawsuit requested a jury trial and damages in excess of $15,000. “The damages are somewhat unspecified. Money is part of her suit, but that's not the primary purpose,” Mr. Baker insisted. “We want to right this wrong. The solution, if patients aren't being seen fast enough, is not to rush them through faster but to stop understaffing the emergency department. And Patricia White also needs a forum to set the record straight about her reputation.”
Although Dr. Ku said he doesn't like the pay-for-productivity approach, he said Dr. White will have a difficult time characterizing it as an outlier practice. “Nevertheless, there are better approaches to incentivizing care, I think. For example, patient satisfaction scores, and meeting standard quality measures like giving aspirin to patients who are having a heart attack or antibiotics delivered to patients with pneumonia within four hours of ER admission,” he said. “But those aren't commonly used as bonus incentives now. It would be great to shift compensation from productivity toward these measures. On the other hand, being productive is also a vital component to delivering good care. No one wants to sit in the emergency department for eight hours.”
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“[O]ur belief is that Baptist and ERG just wanted to get patients in and out.”
Dr. White's attorney
“I think you'd be hard pressed to find an emergency medicine job that does not pay for productivity.”
Dr. Bon Ku
Thomas Jefferson University Hospital
“I've been forbidden to discuss it.”
Dr. Richard Stromberg
C. DifficileContinues to Plague Patients
Infections with community-associated Clostridium difficile (C. difficile) cause as many as 500,000 illnesses each year in the United States, and the threat of illness is increasing. Scientists are investigating potential sources of infections and working to develop a vaccine that may prevent C. difficile, according to a presentation at the Interscience Conference on Antimicrobial Agents and Chemotherapy in September.
C. difficile mostly causes diarrhea and colitis in hospitalized patients whose immunity has been weakened or whose intestinal flora has been disrupted by antibiotic use. The bacteria create spores, and infections are often spread through spore-contaminated surfaces touched by other patients or health care workers.
The long-term use of proton pump inhibitors may increase patients' chances of acquiring a C. difficile-related illness, according to research presented at the conference. A study of patients admitted to internal medicine at Teiko University Hospital in Tokyo from April to June 2010 looked at 816 patients, 487 of whom were treated with proton pump inhibitors. Of those patients, 19 developed C. difficile-associated diarrhea while only four who did not receive the medication developed the illness. The authors did note that patients receiving the medications were older.
Other scientists looked at food as a potential source of C. difficile illness. Glenn Songer, PhD, of Iowa State University in Ames, found that C. difficile has become the most common cause of enteritis in neonatal pigs, and they are now looking for a route of transmission from animals to humans.
Researchers are responding to studies that suggest that high levels of antibodies to C. difficile toxins may protect against infection. The Centers for Disease and Control Prevention have been working with manufacturers to develop a vaccine to eradicate illness caused by the bacteria. Sanofi Pasteur has acknowledged that they have a whole-toxoid vaccine in late-stage clinical trials that contains weakened C. difficile bacteria to spark the production of antibodies.