Profit-hungry hospitals putting the squeeze on emergency physicians
As many institutions feel the sting of reduced reimbursements under managed care, many are demanding that emergency providers work longer hours, with fewer resources, for less money
[Editor's note: This article begins a two-part series on hospitals and emergency physicians. In this issue, we explore some of the turmoil within emergency departments (EDs) under staff contracting. In the next issue, we'll explore life in the ED for salaried physicians under managed care.]
While hospitals have been moving deeper into managed care, EDs are fast becoming the newest battleground in the cost-vs.-revenue war. In the fight by institutions for financial viability, some emergency physicians see themselves as unwitting commodities in the struggle to reap profits and stave off economic doom, many critics of managed care say.
"Physicians need to become acutely aware of the role that hospitals have handed them. We not only have to treat patients today but also have to handle them carefully to produce revenue," says James G. Adams, MD, vice chairman of emergency medicine at Boston's Brigham and Women's Hospital, which last year racked up some 47,000 ED visits.
As health care commodities, many shell-shocked emergency physicians feel unprepared for the rigors of battling with MCOs over money, Adams says. They tend to view themselves more as "the small kid on the block" than the latest road warriors of managed care. "Hospitals want doctors to be strategic players. But they don't understand emergency medicine. They have no patience with things like EMTALA or patient-dumping laws," says Adams.
In the uneasy mix between dollars and medicine, the relationship between hospitals and emergency physicians has not been getting better, according to several physicians who spoke with The Managed Care Emergency Department. With few exceptions, hospitals are generally demanding more of physicians and giving up less as reimbursements from payers tighten and risk-sharing spreads across the map.
Facilities are demanding longer hours for less pay
"Hospitals are expecting physicians to reinvent the ED, to make them, if not profit centers, at least to pay their own way," says Adams, who acknowledges that practitioners don't talk easily about these matters for fear of losing their jobs.
Hospitals are routinely demanding more by insisting on longer working hours and more sensitivity to cost-controls. Meanwhile, they're negotiating tougher terms on staffing contracts that often result in lower pay and less clinical independence, some physicians allege. Hospital administrators are also toughening their stance on patient utilization by exacting narrower limits on drug protocols and ancillary services such as lab work and imaging.
Physician need to fight back by insisting on greater political autonomy and aggressively negotiating new policies with hospitals and medical groups whenever it's right, says Bob McNamara, MD, medical director of the residency program at Allegheny University of the Health Sciences, a system of three teaching hospitals in Philadelphia, PA.
Individually, physicians aren't overtly feeling these pressures, says McNamara.
But, the message is clearly getting across to physician practice management groups and contract staffing firms, McNamara says. By some estimates, these bodies currently employ more than 50% of hospital-based emergency physicians, and they wield enormous influence, McNamara adds.
Hospital administrators and physicians contacted by The Managed Care Emergency Department refused to talk openly about these tensions. But privately many believe the tensions have spilled directly into patient care areas and manifest themselves in the growing use of physician profiling and increased clinical documentation, which many argue has stymied independent clinical decision-making.
Even the Medicare program is getting into the act of looking more over physicians' shoulders, critics say, as evidenced by the controversial new evaluation and management documentation guidelines coming out of Washington, DC. While physician profiling and tougher productivity demands are more common in other specialties, some emergency practitioners feel they see the trend moving into emergency medicine.
"Managed care has been identified as the villain. But issues like pre-authorization and prudent layperson are really the tip of the iceberg. What's really bothering emergency physicians today is tantamount to a crime," McNamara says.
If practitioners complain, they face job loss
With group practices fighting for hospital contracts, "if practitioners complain about their problems, they face being cut from the hospital's medical staff or worse, losing their jobs with the group. It's that simple," says a Florida physician who requested anonymity. Within the past two years, the physician told MCED, her hospital, a 375-bed facility near a large urban center, has asked her to work different shifts, stay longer hours, and participate more actively in hospital business meetings, which often take place on her off-days.
She also says the medical group, which holds the contract with the hospital and four other acute-care facilities in the area, has forced members into additional risk-sharing contracts without the medical staff's consent and despite continual downward pressure on capitation rates. The result has been a gradual drop in reimbursements for the group, due partly to financial turmoil among the large MCOs serving the market. The net effect, the provider says, is that most physicians' incomes have been largely frozen over the past three years. Yet, they have little say in the matter. (Not all hospital-physician relationships are bad. For a different viewpoint, see the article on page 61.)
Yet, despite these incidents or perhaps because of them, the growing trend in emergency medicine has been toward greater physician involvement in managed care, says Adams. On the positive side, practitioners are becoming more financially and politically astute. And they often hold advantages over hospitals and MCOs, although they frequently fail to exploit them, some observers says. These include:
· Realizing what they have in common with hospitals. In fact, physicians and medical facilities are natural allies, says Adams, because they both represent a gateway for patients to an array of services. And, they both hold the key to and determine the level of access to expensive clinical specialties. Given these similarities, hospitals and physicians should be partners rather than adversaries.
· Exploiting the acute-care nature of the specialty. The gatekeeper's role played by emergency medicine has given providers a voice beyond the hospital's walls. The advent of systems integration and multi-hospital group practices has given ED providers greater leverage than before because now EDs can financially affect a more complex, expensive bureaucracy, says McNamara. Yet, physicians often fail to look beyond their individual hospitals.
· Utilizing the specialty's relative independence. However, despite the growth of integrated systems, emergency physicians are able to keep a certain independence given the specialty's nature, says Christopher Knuth, MD, vice president of finance at Infinity Healthcare, a 50-member group in Milwaukee, WI. In Milwaukee, for example, the health plans continually warn hospitals to keep patients out of the ED. "But, in fact, 85% of patients will continue to use us no matter what the MCOs say," Knuth says. This means that emergency physicians aren't as dependent as other providers on contracting. The patient's will come no matter what, Knuth says. (For additional remarks by Knuth on leveraging MCOs, see the article on page 65.)
· Tapping into novel ways to hold down costs. The growing use of observation units and urgent care centers, Knuth says, clearly demonstrates that the specialty can bend and not crack under pressure. Hospitals aren't quick to recognize how much room there is in the ED for lower-cost alternatives to admitting patients and the willingness of practitioners to use them, he adds.
But are these advantages enough to win respect? McNamara of Allegheny University worries that the real source of the problem isn't with hospitals but with the growing wave of practice management and contract staffing firms. These organizations wield an almost absolute power over rank-and-file practitioners, and they are ruining the specialty, McNamara claims.
Contract staffing is emergency's dirty little secret
The contract-staffing model, which is so pervasive today, prevents physicians from exploiting many of the above-cited strengths. Why? "Because when physicians speak up, they face losing their jobs," McNamara alleges. "It's one of the dirty little secrets of our specialty," adds McNamara, who is the current president of the American Academy of Emergency Medicine in Philadelphia. The five-year old group consists of some 2,000 physicians who have broken away from the Irving, TX-based American College of Emergency Physicians over ACEP's alleged refusal to advocate for the rights of individual emergency providers. The group is opposed to the growing wave of contract-staffing firms and to the large, corporate, practice-management concerns that have allegedly stripped individual physicians of bargaining rights over their pay and contracts and have brought corporate medicine into the ED.
"These entities take 20-30% of physicians' fees off the top and have allowed hospitals to threaten some 25% of physicians with job loss. That to me is ruining the specialty," McNamara says.
ACEP President Nancy J. Auer, MD, dismissed McNamara's remarks. "Many physicians like to work for the large groups because they feel secure in getting a steady paycheck," she told MCED. Besides, only 18% of ACEP members belong to large contract staffing firms. The rest work for hospitals or independent medical groups, Auer says.
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