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Private Equity Faulted for Profit over Patients

SoRelle, Ruth MPH

doi: 10.1097/01.EEM.0000791888.04767.2e
    Figure
    Figure:
    private equity, ED management, EM jobs

    A lecture presented at an ACEP ED Directors Academy this spring has amplified criticism about the role of private equity in emergency medicine, creating some buzz on Twitter, garnering reproaches from two specialty society presidents, and giving rise to a new advocacy group seeking to empower emergency physicians.

    It didn't attract much notice the first time Kirk Jensen, MD, MBA, the president and CEO of Healthcare Management Strategies, presented his take on how best to ensure flow through an emergency department. That was at a meeting of the Envision ED Patient Flow Collaborative in July 2017 when he was the chief innovation officer for the contract management group.

    He outlined in the slide presentation his definitions of the best way to use physicians, advanced practice practitioners, and nurses in a busy emergency department, maximizing efficiency and minimizing staffing costs, which he said are 75 percent of emergency medicine group costs.

    Dr. Jensen advised employing the least expensive resource to accomplish the mission, including:

    • Advanced practice practitioners (nurse practitioners and physician assistants) who he said could see as many as 25 to 35 percent of cases effectively and “independently.”
    • Family practitioners or internists who could see 75 percent or more cases that emergency physicians see in some EDs for a lower staffing cost.
    • Standard operating procedures and treatment protocols developed and implemented by nurses.
    • Knowledge that residents in the ED are only a net gain when they are in their final year.

    APPs and Internists

    But the situation had changed by the time Dr. Jensen addressed the American College of Emergency Physician's ED Directors Academy this past April. He acknowledged the operational challenges, including the COVID-19 pandemic and the use of telemedicine to enhance patient flow, optimize safety, and decrease exposure, all resulting in a nationwide decrease in ED visits of 42 percent.

    He compared the ED with a production system in which patients arrive, wait, receive service, and exit. “Advanced practice practitioners have a range of patients they can see,” Dr. Jensen said in a phone interview. “Another choice is to add a family practitioner or an intern, who might not want to work in the emergency department full-time and handle critically ill patients.”

    Making those kinds of determinations means understanding the numbers that guide the emergency department—volume by the day of the week and the hour of the day as well as patient complexity, he explained.

    “Then if you understand and appreciate what your health care providers can handle, then it's just like solving a puzzle,” he said. Complicating the situation in the future will be going from too few emergency physicians to as many as 10,000 more than there are existing jobs by 2030. (Emergency Medicine Physician Workforce Projections for 2030. April 9, 2021; https://bit.ly/3aQb6CZ.)

    Who you hire, however, might vary with the supply of providers, Dr. Jensen said. “One might have a philosophical approach where you say, ‘physicians first.’ With a physician, I get a wider range of skill sets,” he said. “They have the ability to handle any and every patient coming in. So you might say that is how I want to go.”

    But another person might think that advanced practice practitioners “do a bang-up job in the emergency department,” Dr. Jensen said. “I have a pool of talent, and I need to add coverage. Advanced practice practitioners are less expensive, so I will go with one of those. However, they have about 50 percent of the productivity of a physician and on average cost about half of what a doctor makes; there's no net gain.”

    As he wrote in his 2017 slides, “Emergency physicians may be the scarcest resource in the ED, but they are not the most valuable resource.” Nursing staff, particularly RNs, play a vital role, effectively running the department in some settings: “It is the nurses who keep patient care and throughput flowing,” Dr. Jensen said.

    He said he does not know what 2030 will bring. When there were too few emergency physicians, the law of supply and demand worked. “Then as an emergency physician, I am a valuable resource that people will want to attract, acquire, and retain,” Dr. Jensen said. “If I am the person staffing, physicians are a precious resource. If there is a surplus of physicians and I am looking for a job, I am still valuable but not quite as precious. There is more threat of competition.

    “I am a huge fan of a strong physician-based practice environment. If there is relative scarcity, the advanced practice practitioners augment physicians when there is a clear-cut set of cases they can handle effectively,” said Dr. Jensen.

    If there are more than enough emergency physicians, then they could be considered in competition with midlevel practitioners and even residents. He counts first- or second-year residents as zero FTEs and not part of overall productivity. “What they provide is offset by the supervision and time needed,” he said.

    Wall Street's Role

    Dr. Jensen's presentation created some pushback on Twitter, with Mitchell Li, MD, tweeting a screenshot of one of Dr. Jensen's slides and saying his take on staffing was part of Wall Street executives enabling “the illegal and unethical corporate practice of medicine by owning an ED contract on paper but stripped of all power by the corporate group in exchange for a fee.” (April 11, 2021; https://bit.ly/3wN9p1m.)

    Dr. Li, the chief medical officer of the American Academy of Emergency Medicine's locums group and of Thrive Direct Care in Chicago, said he was concerned that encroachment of corporations into emergency medicine had turned physicians and staffing into a commodity. “To say something like 75 percent of your costs are staffing is indicative,” he said. “It should be 95 percent or more because that is what you do. What they are saying is we can decrease staffing costs, and then you have a higher margin for investors.”

    Dr. Li said he was worried that such companies look at staffing as an expense and not at quality or expertise. The growth in emergency medicine residencies have been fueled by corporate medical entities, he said, giving rise to a surplus, so they are looking for alternatives. Could emergency physicians staff urgent care facilities? Could they make residency programs a year longer?

    Dr. Li said he is concerned about the future. “Not only are we trying to replace emergency physicians with family doctors but with nurse practitioners and physician assistants,” he said. “We've taken one step forward and 20 steps back.”

    Dr. Jensen's presentation, which was available on the Envision website, played a factor in Dr. Li and others, including Robert McNamara, MD, a founder of the American Academy of Emergency Medicine, starting Take EM Back, an advocacy group encouraging emergency physicians “to advocate for their patients and communities without fear of job loss, disciplinary action, or other professional retribution.” The organization released a white paper July 12 explaining its vision. (https://www.takemedicineback.org.)

    AAEM, ACEP Weigh In

    Lisa Moreno-Walton, MD, the president of the American Academy of Emergency Medicine, agreed that Dr. Jensen's point of view is echoed in corporate medicine. “We 100 percent disagree with the notion that emergency physicians are not the most valuable resource in the emergency department. No one comes to an ED for any other reason than to see a physician,” she said. “Physicians support everyone else who works there. We are the most highly trained and knowledgeable about roles in the ED.”

    Dr. Moreno-Walton also decried Dr. Jensen's comments about family physicians and internists working in the ED. “He undermines the sacrifice these young people have made by saying you don't even need to be trained in emergency medicine to practice it,” she said, adding that nurse practitioners and physician assistants should not be practicing independently because some “don't know what they don't know.”

    She agreed that at least 75 percent of the expense of running an emergency department is staffing, but they failed to mention that the other 25 percent goes to corporate owners who make more money than the physician without providing a real patient service. And she disagreed that physician efficiency can be measured in patients seen per hour. “They never look to see how often the physician makes the right diagnosis,” Dr. Moreno-Walton said.

    Mark Rosenberg, DO, MBA, the president of the American College of Emergency Physicians, said he knows Dr. Jensen well and respects his intellect, but that a cookie-cutter approach to staffing will not work. “What I've found is there is no formula that works screamingly well and consistently everywhere,” he said. “The most important person to help decide the right staffing patterns is the medical director of the hospital emergency department in conjunction with the goals and objectives of that institution.”

    The predicted excess number of emergency physicians could be anywhere from 6000 to 10,000 by 2030, but the most crucial factor is the significant decrease in emergency department visits for various reasons, he said. “Patients were told unless you absolutely need an emergency department, stay away, and they did,” Dr. Rosenberg said. “We know also that kids did not get sick from flu this year. We did not get a lot of heart attack, stroke, or appendicitis patients. But we found that a lot more people were dying at home. They didn't want to go to the emergency department alone,” he said.

    Meanwhile, emergency physicians were still graduating, and fewer patients were coming to the ED, Dr. Rosenberg said. “The future was accelerated because of this pandemic that caused a mismatch,” he said. “The report showed the mismatch in the future, but we are seeing it now.”

    Current reports show emergency department volumes are increasing, Dr. Rosenberg said, but many EDs are hesitant to hire because of the uncertain future. “Normally, you make sure you are fully staffed for the flu season, but there wasn't one last year.”

    Does the hospital want every patient seen by a board-certified emergency physician or does it just want every patient seen? he asked. “That changes the staffing. As much as I like and respect Dr. Jensen, I know you can't oversimplify this. You have to go back to the uniqueness of each emergency department and its local leadership.”

    The other critical factor is the nursing staff the department has, Dr. Rosenberg said. “Emergency departments are best when they're led by an emergency physician, but I need the whole team there to make it work. I need a full complement of nurses [and] an operational and functioning laboratory and radiology. If any of these are not fully staffed, it's going to slow everything down.”

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    Access the links in EMN by reading this on our website, www.EM-News.com.

    Comments? Write to us at [email protected].

    Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

    Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
    • [email protected]3:09:49 PMThe slide “Leveraging your available talent pool” featured/tweeted by Dr Li, and by association, Emergency Medicine News, is from Staffing Your Emergency Department Efficiently, Effectively and Safely: Core Concepts, a July 2017 presentation & conversation held with an audience of close to 100 experienced emergency physicians, APPs, nurse clinical leaders and quality improvement people. It is one slide cherry-picked from a seventy-slide deck. The slides were the basis for a thoughtful and considered presentation and discussion on staffing one’s emergency department efficiently, effectively and safely. The slide deck included references to both ACEP’s and AAEM’s past publications on safe and reasonable clinical patient loads within the emergency department. The slide (and the slide deck), on its own, was never meant to be a stand-alone essay on the subject of supporting ones staffing efforts. The slide - Leveraging your available talent pool - was a brief entry on how to facilitate adding extra coverage, when needed, in hard to staff emergency department locations. And, as mentioned previously, it was part of a much richer and deeper discussion on staffing one’s Emergency Department efficiently, effectively and safely. The bullet “Family practitioners or internists can see up to 75% or more of the cases that emergency physicians see in some EDs (for a lower staffing cost…) referred solely, in 2017, to the subject of adding extra coverage in very hard to staff locations, and not to a generalized approach to ED staffing … The slide immediately following the Leveraging your available talent pool slide has the following bullet point: • Ease of recruiting and your group’s historic staffing retention rate are crucial drivers of your staffing strategy - Certain EDs are easier to staff than others. Staffing in a major city or suburb with several emergency medicine training programs and plenty of physicians and nurses is vastly different than staffing and scheduling an ED in a rural area with no training programs and fewer amenities. This slide was not presented at the ACEP EDDA and certainly not in the spring of 2021. A version of this slide was included in a 2008 ACEP Scientific Assembly presentation on Emergency Department Staffing. Highlights of the ACEP SA 2008 presentation were impartially covered in an August 2009 ACEP News article Staffing an ED Appropriately and Efficiently authored by Martha Collins. Going deeper, it is one slide cherry-picked from a seventy slide 2017 deck and tweeted out by Dr Li, and now amplified by EMN... It is unfortunate that Emergency Medicine News chose to amplify this approach, inciting further political controversy, rather than publishing a measured and thoughtful piece on the ins and outs of Emergency Medicine staffing in 2021 & 2022. The article contains other factual errors, as well as errors of omission, that could have been easily avoided by simply fact-checking the article prior to printing. I have detailed some, but not all, of those errors in a letter submitted to both the author and to the editor. Kirk B Jensen MD
    • alexanderkuehl1:50:04 PMI detest large multilocation groups and fee for specific service emergency departments. I have supervised every possible kind of emergency provider. The most important thing is that the provider knows his limitations and when to ask for assistance. Of particular concern to me is for providers (no matter the level) to play the percentages on patients presenting at ED and NOT rule out the zebras that could maim or kill. For example, sudden low back pain should not be discharged without a rectal exam for tone.
    • bellwg6:09:56 PMI first must disclose that I am not a board certified emergency physician. I am certified in family medicine. So saying, I have been practicing EM for ore than 20 years, and have strong opinions on this subject. How often do you see a patient who appears simple only to realize that the problem is life- or limb-threatening. I always feel that the ED is like a box of Cracker Jacks; you don’t know what the surprise in the box may be. That is why someone with experience or training needs to be in the ED. Extenders can see many patients who have minor problems, but need support from mergency physicians to help them with more complex problems. As for family medicine/ internal medicine physicians, there is a basic difference in the mindset with EM. While primary care specialists tend to look for the most common causes of problems, emergency medicine specialists need to look for the snake under the rock. This frequently involves using more testing and more imaging than one would do in an outpatient setting. While some may argue that this is not cost-effective medicine, I believe that our goal is to save patients lives and limbs from preventable catastrophes. Emergency department functions as the backstop for medicine. It provides an important safety function providing care for people who may or may not have critical illnesses, and hopefully is able to tell the difference. This may not be completely consistent with corporate profits, but should not be cheapened to that point.
    • thedrmike12:32:39 PMWell, geez, physicians and midlevels are really expensive. Why staff the ED with providers at all? I mean, who really needs them? How about staffing with those only with a high school degree or even cheaper computers with Google access so patients can diagnose and treat themselves?!
    • rjybarra510:46:44 AMRevolutionary science is when whole paradigms change, as opposed to normal science, which is incrementalism. In Texas, we passed a bill that allowed independent freestanding emergency centers to exist. Eureka…goodbye, TeamHeath and EmCare! We started a FEC Association, by physicians, for physicians. There were a few administrative individuals on the board, but the bulk were physicians. ACEP and AAEM had sections/interest groups started. All “was” great. Fast forward 11 years. Aside from the group I currently work with, many independent FECs (and the association) have become “corporate.” Ideally, private practice models of owner/operators can be revived. That would be revolutionary not just in Texas but in other states. Patients over profits can occur. The Texas Medical Board continues to foster the philosophy of physician autonomy to make patient care the “bottom line.” Corporations serve their stakeholders, and that’s all well and good, but not in medicine. An FEC association that serves the physicians autonomy in private practice might be a step in the right direction. Normal science again, followed by revolution.