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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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.