The emergency medicine workforce study released by the American College of Emergency Physicians in April made a stunning conclusion: Without significant changes, the specialty will have 10,000 more residency-trained emergency physicians than available jobs by 2030. (Emergency Medicine Physician Workforce Projections for 2030. April 9, 2021; https://bit.ly/3aQb6CZ.)
The workforce identified eight considerations to drive meaningful change to avoid this calamity:
- Raise the bar to ensure consistency across emergency medicine residency training.
- Support practicing physicians to encourage rewarding practice in all communities.
- Ensure appropriate use of nurse practitioners and physician assistants to protect the unique role of emergency physicians.
- Set the standards for emergency medicine so every patient has access to a board-certified emergency physician.
- Broaden the umbrella to expand emergency physician scope of practice.
- Expand the reach of emergency medicine to ensure that no community is left behind.
- Stop the proliferation of emergency medicine residents and residency programs.
- Ensure business interests are not superseding the needs of educating the workforce. (ACEP. April 21, 2021; https://bit.ly/2QvSDEY.)
All of these considerations are ripe for meaningful discussion, but the last deserves special attention. The growth in the number of EM residency programs over the past decade is staggering. The Accreditation Council for Graduate Medical Education recognized more than 100 new emergency medicine residencies between 2010 and 2020, a 75 percent increase. This is by far the largest percentage increase in the house of medicine. (EMN. 2019;41:6; http://bit.ly/32mT0Sl; data from https://bit.ly/33RfEVZ; https://bit.ly/2SZDX1H; https://bit.ly/3yiuEdj.)
The merger of existing osteopathic EM programs with allopathic EM programs already recognized by ACGME is a significant component of this increase, but between a quarter to a third of the new programs are sponsored by for-profit health care organizations. The actual number is difficult to pin down because several programs changed their employment structure.
HCA is the largest for-profit provider of emergency medicine training programs. This publicly traded health care behemoth created 14 new EM programs with more than 150 residents in each class since 2017. It now has 17 emergency medicine residencies in Florida (10), California (two), Texas (two), Virginia, Nevada, and South Carolina (one each). (HCA Healthcare. https://bit.ly/3bx4qd9.) Several more programs are also in development by HCA to accept residents in the near future.
US Acute Care Solutions sponsors seven programs with a total of more than 60 residents per class. (USACS. https://bit.ly/3uVyJSt.) These for-profit organizations rapidly expanded their market share of graduate medical education in the past decade, and, particularly in the case of HCA, boast about their accomplishments; one EM job listing for a program director at an HCA-sponsored EM program states the following:
“HCA is now the largest provider of Graduate Medical Education for Physicians and Surgeons with over 250 academic programs nationwide. With new programs beginning every year and existing programs expanding, we are always in search of physicians with a passion for teaching others.” (HCA recruitment ad. https://bit.ly/3uX0CtE.)
HCA, with its 186 hospitals, is the largest hospital system in the United States. (Becker's Hospital Review. Dec. 22, 2020; https://bit.ly/3hLc0VR.) Financially, this company is a juggernaut with a net profit of $3.8 billion on $51.5 billion of revenue in 2020. Its first-quarter profit for 2021 was $1.4 billion. (Fierce Healthcare. April 22, 2021; https://bit.ly/3eWQxHB.) All of this came during an international pandemic in which many hospitals lost enormous amounts of revenue.
There is nothing wrong with making money, pleasing investors, or looking for innovative ways to provide more efficient, cost-effective products and services. HCA is a successful company using these metrics, but these ambitions create a lot of controversies. HCA settled the largest health care fraud case ever with the Department of Justice in 2003, paying $1.7 billion. (Department of Justice. June 26,2003; https://bit.ly/33URKca; The Atlantic. Aug. 6, 2012; https://bit.ly/33RS7E8.) And an audit by the Office of the Inspector General this past April concluded that an HCA-owned hospital must pay back $23 million in overpayments by Medicare. (Modern Healthcare. April 2, 2021; https://bit.ly/3bzcNFk.)
I reported in January 2017 on HCA's initial efforts to develop emergency medicine residencies. An HCA recruiter looking for EM faculty to staff its programs told me that their strategy was simple: “Train and retain.” They started 14 programs over the next four years. That certainly creates a lot of opportunity for retention while also being a major facilitator of the rapidly changing landscape of the EM job market. (EMN. 2017;39:1; http://bit.ly/2ZhrF6k.)
Partners with Envision
Interestingly, HCA utilizes the physician staffing company Envision to provide emergency care in many of its facilities. Envision, purchased for $9.9 billion by the American investment firm KKR, is a market leader in staffing the nation's emergency departments.(Businesswire. June 11, 2018; https://bwnews.pr/3hwrkW9.) Envision is also no stranger to controversy. One investment manager accused Envision of “deception or aggressive use of reimbursement.” (Forbes. May 15, 2018; https://bit.ly/3yktH4k.)
More concerning for emergency physicians, however, Envision also appears to be interested in utilizing advanced practice providers in place of residency-trained emergency physicians. A recent internet flyer titled “Raise the Standard for Emergency Medicine” offers a “patient-centric care model” where “[o]n-site APP coverage is supported by board-certified emergency medicine expertise.” The flyer indicates that access to an emergency physician is sometimes provided remotely. It even has a picture of a patient looking at a computer screen with what appears to be the attending physician. How this raises the standard is not entirely clear. (Envision Physician Services. https://bit.ly/2Rh2Sxj.)
A previous version of this same flyer makes an even more concerning statement. It stated in bold text, “Within Envision physician services, the average hourly compensation for APPs is nearly 66% less than that of physicians.” The flyer was modified before the release of the ACEP workforce report and is no longer available online. (A screenshot of the original is shown.) Nonetheless, the implication is clear: If you use Envision to staff your emergency department, you will decrease costs and increase profit because they use cheaper labor. It certainly opens up a lot of questions about the implications of Envision's ED staffing strategy on the quality of patient care.
How does Envision's staffing concept square with HCA's massive effort to create a whole bunch of new residency-trained emergency physicians? Perhaps HCA will guarantee their residency graduates' future employment. Still, with the predicted surplus of available EM residency graduates in the next decade, one could reasonably assume that even HCA's graduates will not have a strong negotiating position in the years to come.
Another consideration is that mammoth companies like HCA can force the eventual closure of EM training programs at other health care institutions that spent decades refining the process of educating medical school graduates to staff the nation's emergency departments. The clinical learning environment for many, if not the majority, of these programs is at hospitals that primarily provide care to economically disadvantaged patients.
An oversupply of EM training programs potentially discourages future medical school graduates from going into a specialty that may not provide them with a job. Given the extraordinary debt taken on by most medical school graduates today, finding work after residency is imperative. At some point, medical students will choose another specialty, and the number of applicants to EM programs will go down. The impact of this on hospitals with EM training programs that predominantly provide care to unfunded patients is unknown at this time, but losing their program due to a lack of applicants would potentially be hard on them financially.
It is reasonable for any health care organization to pursue staffing models that combine quality care with cost efficiency. But the ambition in health care to create more profit can lead to poor decisions about what combination of providers will do the best job. It is unlikely these businesses, particularly those inexperienced in training physicians, possess the ability to understand the far-reaching implications of the rampant growth of resident training programs in emergency medicine (or any other specialty for that matter). It is not the nature of any for-profit business to do so. Their primary concern is how to maximize the success of their business regardless of its effect on other companies or the specialty. That imperative is the job of regulatory organizations (e.g., ACGME), which I will write about in a future column.
Dr. Adleris a practicing emergency physician at the University of Maryland Medical Center, where he serves as the director of compliance and reimbursement. He is also the vice president of practice improvement at Brault Practice Solutions, where he oversees provider education and group practice analytics. Follow him on Twitter@ercoderguy. Dr. Cookis the program director of the emergency medicine residency at Prisma Health in Columbia, SC. He is also the founder of 3rd Rock Ultrasound (http://emergencyultrasound.com). Friend him atwww.facebook.com/3rdRockUltrasound, follow him on Twitter@3rdRockUS, and read his past columns athttp://bit.ly/EMN-Match.