Why Do EM Physician Groups Get Replaced ?

repel boardersThe last post on this blog (Contracting the Hospital’s Emergency Department Mission) got a lot of hits, so I thought I would follow up with another post on the same subject, this time dealing with why emergency physician groups get replaced by their hospitals. The reasons, of course, might dictate how these groups might want to respond when their practice is threatened with takeover by another EM group. Typically a group of emergency physicians that is staffing a hospital ER (or ED, as we now call it) learns of this threat when its hospital administrators advises the group that the contract is going out to bid. The current EM group may or may not be invited to bid on the staffing contract, which is a pretty good indicator of things to come. There are many reasons why hospital ED staffing contracts go out to bid, or are cancelled; and sometimes this has nothing to do with the existing contract holder’s success at meeting the C-suite’s expectations.

Hospitals may put the contract up for bid because their hospital-affiliated system has decided to put all the EDs at all the different hospitals in the system out to bid to a single large EM group in the hope of getting a ‘better deal’, eliminating subsidies for these contracts, or standardizing care and reducing equipment and staffing costs across their system, or forcing the large EM group to pick up loss-leaders (sites that have a poor payer mix) along with the better sites. The rationale for this approach eludes me, as it seems like a prescription for a lean towards the mean, but it continues to be a factor in EM group turnover.

When it comes down to the decision of a hospital administrator for a single hospital, a threatened ‘request for proposal’ for the ED contract usually reflects one or more of the following: the perceived need to eliminate a stipend supporting the EM practice; frustrations of ED nursing staff with the existing EM group; poor performance of the EM physicians with metrics like patient satisfaction scores or ‘time to provider’; poor relations between the EM group physicians and some of the more important (i.e. revenue generating) medical staff; aggressive pursuit of the contract by another EM group; a new administrator groping for a way to make his mark in his new role (the dumbest reason); failure to deal with ‘problem’ EM physicians in the group; multiple complaints by patients about the ED (usually an excuse for the RFP rather than a reason); or just a timely testing of the marketplace for EM contract services. Curiously, there are some issues that don’t seem to be raised as justification for a change (and perhaps ought to be): grossly excessive charges and/or up-coding by the EM group; aggressive balance billing by an EM group that avoids contracting with health plans participating with the hospital; lack of active participation by the EM group in hospital medical staff committees and affairs; lack of EM physician involvement in the community, and the like.

Turnover of an EM group that has a long-standing relationship with a hospital is often a sad, frustrating, and disruptive experience, displacing very good doctors from their homes, school districts, and communities; and hospital administrators should not take this on without good reasons. Sometimes EM groups, or the group’s management, become complacent, distracted or disinterested. Issues with the nursing or medical staff may fester; or the group loses some of its dynamism, and fails to bring on new blood or mentor upcoming leaders; or find ways to continuously improve the services to ED patients. In such cases, turnover through an RFP can be a necessary, if unfortunate, solution, or a catalyst for necessary changes. Unfortunately, hospital administrators can easily find a number of excuses to justify putting an ED contract out to bid even when the EM group and its individual physicians are stellar performers. Administrator will sometimes try to replace the EM group, but retain most of the physicians in the group under ‘new management’ which it is hoped will be able to meet the new or unmet demands of the administrator while tempering the angst of medical and nursing staff that have come to respect and rely upon the individual EM physicians responsible for their patients. Sometimes this works, sometimes it fails miserably. Much depends on the cohesiveness of the EM physicians in the group, the support of the medical and nursing staff, and the ability of the group’s leadership to weather the storm.  In some cases, the RFP re-energize the docs in the group to step it up and rise to the occasion.   EM practice is incredibly demanding, and requires EM group leadership that goes above and beyond what most physicians are willing or able to do, and a team of physicians that are truly invested in their practice.   Those EM physicians who do their shift, go home, and forget about the ED until their next shift are likely to experience the threat of losing their practice more than once in the professional career.

Some EM groups, faced with contract turnover, might want to consider merging with another group that can bring some of the talent and expertise to the table that their own group might be missing. Other EM groups that, after careful and thorough self-assessment, believe they deserve to retain their contract and are willing to fight for it; should harness this energy, recommit to their team members, stand on principle, and prepare to repel boarders.



Why Do EM Physician Groups Get Replaced ? — 10 Comments

  1. Very nice article. As hospital margins continue to erode, hospital administrators will increasingly look for efficiencies, quality, and physician leadership from their EM groups to help manage the turbulence in today’s health care environment.

  2. And then there is the HCA/EmCare “marriage” where HCA takes a cut of the profits generated by the ED docs and mandates that all HCA hospitals have EmCare as their provider of service. Become an EmCare employee or leave. Now EmCare can have revenue generating “metrics” (aka: mandates) for the doctors and fire the docs that don’t admit the magic % of patients seen or order enough high dollar tests. (the EmCare contract allows for firing “without cause”.

  3. I personally disagree w/any issues about and/or concerning problematic issues w/HCA. Other ED physicians I’ve known personally who been w/HCA have had nothing but GREAT experiences. That’s just my personal opinion. If one gives 110% at HCA and/or w/patients and staff there. There are no negative outcomes or problems w/HCA. Again my personal opinion w/physicians and my own experiences in the Southern Virginia areas w/HCA in the ED. If I missed the main content (subject) of this blog/update about HCA. My bad I just skimmed the article at home.
    Thank You,
    Anthony M Salerno, D.O.,MBA

    • Tony, my blog post was not specifically about HCA or any other hospital system per se. Dr. Caliendro (and others elsewhere) felt that the concerns in my blog were reflective of some issues with HCA, but I personally have no direct experience with this hospital system. I am aware that HCA does have a relationship with EmCare, but this is not a totally unique situation. I suspect there are upsides as well as downsides for the hospitals, the payers, the EM groups, the docs, and the patients in any such exclusive or preferential staffing-contract relationship, and it is up to the parties involved to weigh and consider the implications. ACEP has chosen to mostly sidestep the impact of these and other aspects of staffing contract relationships on ACEP members at large and on the specialty, AAEM has chosen to address these issues directly. I do believe that the elimination of stipends supporting EM practice at sites that do not have the payer mix to support qualified EPs ultimately lowers the tide for all EM ships, and strands quite a few EDs on hard rocky shores.

    • (Response to Tony:) Your HCA experience differs from mine, and from that of every emergency physician I know in HCA’s TriStar Division. Perhaps it’s just TriStar, and the rest of HCA is a completely different company. Here, HCA corporate executives with no EM background or experience chose EMR and CPOE systems for their EDs, not just without consulting emergency physicians, but over the objections of those physicians. They chose Meditech, which KLAS surveys have indicated is the single worst EMR/CPOE system in the industry. This horrible decision, combined with their billboards advertising ED wait-times and obsession with metrics that have (at best) a very loose connection to actual quality, have made the HCA emergency physicians I know miserable.
      Even worse, HCA (and recently other hospital chains too) is now replacing excellent emergency medicine groups solely for extra revenue. Groups that take no subsidy at all; deliver high-quality, state of the art care; have excellent relations with nurses and the medical staff; generate very few patient complaints; participate in every insurance plan the hospital CEO wants; etc. — groups that are literally flawless and cannot be improved upon. HCA, no longer content with billing and collecting just its own hospital charges, is replacing such groups because it has formed a joint venture with EmCare that allows EmCare to kick back to HCA some of the money it takes from its emergency physicians’ billed and collected professional fees. Even the most perfect independent, physician-owned, emergency medicine group cannot compete with that. It is bad enough that corporations like EmCare and Team Health have their hands in our pockets, now HCA and other hospital chains do too.

    • Two years ago I would have wholeheartedly agreed with you. I’ve been at an HCA facility since 1995, and felt a deep commitment to developing and maintaining a synergistic relationship with the hospital. We have a great medical staff, fine nursing, a pretty good physical plant (with some growing pains). But now….

      Whose fault is it. Why ours, of course. We need to just say “enough”.

  4. The problem now, of course, is that even an absolutely perfect EM group is likely to be replaced, because a CMG will use a joint venture to hide a kickback to the hospital – bribing it for the ED contract. We can no longer compete based on quality, even if we aren’t getting a subsidy from the hospital. Unless this phenomenon can be reversed in the very near future, the private practice of emergency medicine will die out completely.

  5. A year ago, we,too, would have said we were happy and not having major problems with HCA. But that has changed with the “marriage” of EmCare and HCA and the feeling I get now is that the bean counters are dictating how the corporation runs. They give lip service to “quality patient care”; but there actions are purely finance driven. Our group has the medical staff behind it, most consider it the best ED in the city, and we have a stable quality group….none of that enough to keep us from getting an ultimatum to become EmCare employees or leave. We told them we would leave and they are backing down because they can’t recruit enough physician to Kansas to cover an ED that sees in excess of 100,000 patients a year. But they are not letting us grow our group and obviously plan to shed themselves of our group if and when they can find enough employees to replace us. If you are one of those who are blissfully happy at HCA, keep your eyes open wide!

    • That sounds exactly like what happened in the Nashville area, except that enough of the docs stayed put that the scheme went through as planned. Three independent, local, physician-owned groups (and one TeamHealth contract) were displaced by the new HCA/EmCare joint venture.

  6. Pingback: Using, and Misusing, Consultants in the ED | THE FICKLE FINGER

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