Emergency physicians often lament the travails of being employed by a hospital or a contract management group, pointing to the difficulty of meeting unrealistic patient satisfaction measures and quality standards. It's a physician's ethical duty, they say, to advocate for their patients first, not to put a business model above them.
EPs also worry about being replaced with cheaper midlevel providers, whether their due process rights will be respected, and if they will be required to order certain tests or admit patients unnecessarily, as was alleged by health care providers who said the for-profit Health Management Associates pressured them to meet targets for admitting patients, a charge HMA denied. (EMN 2013;35:1; http://bit.ly/Y1CN0s.)
But one thing that contract management groups know that emergency physicians often do not is how to speak to the C-suite, the senior executives of a hospital or corporation. An independent emergency physician group that isn't party to such a strategy may find themselves a target for elimination, especially if the ED gets swallowed up by a merger or bundling of contracts.
“After having been president of the American Academy of Emergency Medicine for less than three months, I've already been personally contacted by no fewer than six different emergency physicians about being terminated without due process,” said Mark Reiter, MD, MBA, also a member of Middle Tennessee Emergency Physicians, in EMN's August issue. (“Wrongful Termination Suit Highlights Due Process Gaps,” EMN 2014;36:1; https://bit.ly/1kp4qy.)
Robert McNamara, MD, the lead author of a 2013 study looking at due process, financial pressures, and the ability to advocate for patients, said he recently spoke to a newly graduated resident who was terminated for raising quality of care concerns while working for a major contract group.
“Now she has a termination on her record, and is going to have to explain what happened when she goes to look for other jobs,” said Dr. McNamara, a professor and the chair of emergency medicine at Temple University in Philadelphia. “She can say, ‘Well, I spoke up about the quality of care,’ and people are going to say, ‘We've got a troublemaker here. We're not going to hire this person.’ It's a devastating personal issue early in her career. Why would we embrace an industry that allows that stuff to happen to a naïve, young doctor?”
The American Academy of Emergency Medicine has a wealth of resources for emergency physicians about corporate practice, contract issues, due process, and fee-splitting. (www.aaem.org/em-resources.)
But many emergency physicians say they don't know how to run a business, and many agree that they just want to show up for their shift and take care of patients. Finding employment with an independent group, forming their own group, and negotiating with hospital administrators, however, aren't as difficult as they seem, experts say. Emergency physicians just have to learn to speak C-suite.
Keep in mind how important it is to be proactive, said Mark Mackey, MD, MBA, the vice chairman of clinical affairs in emergency medicine at the University of Illinois and a member of the board of directors for ACEP. It's also vital for EPs to prove they have a team-player mentality.
“In a single hospital group where you're a part owner, which I have been, there's a greater expectation on the part of the group for you to participate in functions related to the hospital, committee work, task force work, more community involvement,” he said. “I don't think I can overstate the importance of that. Really what your viability is going to be based on is how decision-makers value what your contribution is, and that may be your best strategy in order to maintain your income and viability going forward.”
EPs considering forming an independent group or trying to win a hospital contract must also emphasize the business over the patient care component. An independent group that doesn't put the business side first won't survive, which will sabotage the very thing that emergency physicians value most — providing patients with the best care and advocating for them.
John Holstein, a director of Zotec Partners, said it is important to determine the coding, billing, and practice management administrative needs of the hospital. “Hospitals simply don't do professional fee coding, billing, and emergency medicine practice management very well,” he said.
Mr. Holstein said emergency physicians forming their own group also have to do a financial study and projection, define the practice structure and roles of every physician, and determine the staffing model based on volume.
Starting an independent group is appealing because of the risks associated with working for contract management groups, but Dr. Mackey said emergency physicians still need options. “I think we recognize that there are many different types of practice, structures, and governance. We're not in a position to dictate to any particular individual which one they would choose to practice in. I personally strongly believe the more options, the better as it relates to our members and emergency physicians in general.”
EPs who seek to pitch themselves to the C-suite must recognize and devote attention to issues that go beyond providing high-quality emergency care, according to the 2001 ACEP document, “Obtaining, Maintaining, and Retaining an Emergency Department Contract.” (http://bit.ly/1pskMpJ.) “The long-term success of an EP group is dependent upon its ability to address the interests and concerns of the patients, the hospital medical staff, the hospital administration, and the community,” the document said.
ACEP said those looking to start or keep an ED contract should:
- Focus on patient services, considering the variables related to customer satisfaction.
- Formulate a plan for medical staff relations, understanding that a “hospital medical staff's perception of its EP group influences its success or failure.”
- Understand that the relationships among the physicians in a group are vital to success. EPs should define policies on group legal structure and ownership, joining and leaving the group, termination, disability and illness, group leadership, employment contracts, and conflict resolution.
- Develop a formal risk management plan that includes complaint management, customer service training, education in EMTALA and other regulations, quality assurance, risk management, and coding and billing compliance, to name a few.
- Consider projects to allay hospital administrators' concerns about areas that need improvement.
“Emergency physician groups that seek to obtain, maintain, and retain an emergency services contract with a hospital must recognize and devote attention to issues beyond the provision of high-quality emergency care. The long-term success of an EP group is dependent upon its ability to address the interests and concerns of the patients, the hospital medical staff, the hospital administration, and the community. Focus on these interests and concerns often can enhance the EP group's opportunity to provide its patients the very best emergency medical care,” according to the ACEP paper, which was prepared by the Emergency Medicine Practice Committee, chaired by John H. Proctor, MD, MBA.
ACEP has other resources available, which can be accessed even by non-members. Many conferences also offer lectures about how to speak C-suite. Becker's Hospital Review is a good place to start. (http://bit.ly/VkfH71.)
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