Envision bankrupt! Does it matter to you?

Also: ERs on the border on the brink of surge, EM physician pay in peril, employment benefits on decline, rural ED challenges, an NPs act of love for Dad, and a glimpse of future PAs

Top of the week

An Envision bankruptcy was inevitable; what’s next?

I imagine not everybody knows the history, so this is a very brief review. In 2017, there was quite a stir over Envision billing sky high charges to out-of-network ED patients. By the way, this was not unique to them. It also lost $232.5 million that year. In 2018 a private equity firm, KKR, took over Envision for $9.9 billion, and assumed its debt. In 2020 a bankruptcy plan began to be discussed. Since then, Envision has faced a number of financial obstacles. Two of them were the end of balanced billing and rising labor costs. In 2022, the credit rating agency, Moody’s, cautioned about an impending Envision bankruptcy.  Now, Envision owes about $ 7 billion in debt and filiing bankruptcy. How much is that debt worth? About 4-10 cents on the dollar.

Why is this newsworthy? Well, as of 2022 Envision employed about 70,000 health care professionals. It also holds contracts in 45 states. That’s an enormous footprint for a company that has financially failed; and a great number of providers depend on them for stability and financial longevity. The debt will be reorganized, and folks will get paychecks. However, I don't believe that maximizing provider pay for the next 5 or 10 years will be included in its list of priorities. For example, at least 162 administrative layoffs are already planned.

There’s another issue, however. Is this a preview of what’s to come for the remaining big staffing companies? Other big staffing companies also carry concerning levels of debt. Other big staffing companies were adversely affected by the prohibition of balanced billing. They also struggle with labor costs like exorbitant Locums fees, last minute bonuses to hire, retain, and cover critical shifts. 

A third issue. If we thought the EM residency vacancies made news this year, wait till next year. What kind of outlook on EM will medical students have now?

I believe we will begin to see increased number of smaller staffing groups comprised by a handful of seasoned EPs who are trying to get back to putting the provider first, and to direct more profits back into provider pay.

I do believe EM NPs & PAs will navigate the next 5 years from a position of strength. Why? Because you fill an incredible number of staffing hours in EDs throughout this country that has a physician shortage. You pose a savings to EM staffing groups who just lost the ability to balance bill. You, yourselves, produce great revenue that produces wealth for companies.  You are the experts on EM NP/PA pay because you have the data on your paychecks. You know your capabilities and limitations. You know your potential. Many of you have great leadership experience and financial expertise. 

The next 5, 10 years will need you more than when your professions were first created. You have a say in shaping your profession. Your time is now. You got this!

EM Practice

EDs brace for being overrun by patients with the end of title 42 

Opinions of politics and policies aside, what is certain is that EDs are understaffed, under sourced. The staff that does exist are overworked and stressed. Whether it is this surge or a future repeat of a Covid-like illness surge, we need staffing groups and hospital partners to maximize efforts and resources. This includes paying money to staff-up providers and nursing. Overstuffed waiting rooms hold patients with known conditions that need ED beds and care asap. They also hold the patient with the not yet detected ticking time bomb emergency condition.  It is true that EM providers voluntarily select this specialty knowing they can be quickly overwhelmed by the unpredictable. However, when we do know a surge of great volume of patients are coming, we should be supported to the greatest extent possible.

Inflation beats emergency physician pay 

EM physicians were among 7 specialties that experienced a decrease or no change in pay in 2022. Inflation peaked at over 9% and averaged around 8%.  Considering the Envision bankruptcy, one can’t help but wonder about the financial outlook of emergency medicine. It is true that there has been a reimbursement tug-of-war between staffing agencies and insurance companies.  Money is tight. However, providers create an incredible amount of revenue and profit for employers. Is there really not enough money to at least beat inflation? I suspect most of you believe there is. So, the next question is “how exactly are profits being spent?”  The same study cited an average incentive bonus of $51,000 for EM physicians. If you are an EM NP/PA, what was the average incentive bonus in your department. Shouldn’t you have full financial transparency if paychecks can’t even beat inflation?

Twitter takes the temperature of EM physicians

A study looked at tweets by EM physicians from 2018-2022. It found that it was a pretty good medium to see how EM physicians were feeling, and what they were thinking. It showed a significant increase in mental health stress. There’s no question that APPs are also experiencing similar type and degree of burnout. Not everybody can do what you do shift after shift; I don’t blame those that can’t or won’t. For those of you that do, you need to be compensated appropriately. Your shifts need to be staffed with sufficient number of providers. Hospital partners must take real, measurable actions to staff beds with nurses, improve testing turn-around times, and improve the “yes, I accept your admission” experience.

House of Medicine

What happens when money starts running dry? Employment benefits start to diminish. We all know money is tight in health care.  So how is available money distributed?  The 2023 Physican Compensation Report showed that employers are paying more money to move doctor’s geographically to fill needs. However, the majority of benefits are being reduced. The top 3 cuts by percentage were health insurance, malpractice insurance, and disability insurance. 401k contributions cuts weren’t far behind.

Who are tomorrow's doctors?

Is the best of the best really being recruited, or is it the best money that is selecting tomorrow’s doctors. The Journal of the American Medical Association published a study that shows more medical school applicants and graduates come from higher-income families than before. Of course, there are other factors that influence a student's ability to apply and attend medical school. However, money has definitely been identified as a factor between 2014 and 2019.

Hospitals, health systems, and more

What awaits you in the rural setting

Not every provider can work in urban/suburban settings.  US residents continue to push to rural areas to live, and those folks need EM care. Rural settings and the right supervising physician can be a great opportunity for a new grad or junior NP/PA to develop their EM knowledge and skill. Rural settings can also be a great opportunity for an experience EM NP/pa to practice at the top of their license.

Historically, rural EDs were hampered financially by at least 3 factors. A high proportion of Medicare patients who have costly chronic illnesses; overall low volume of patients that does not allow economies of scale like bigger hospitals; and being a sole community hospital that absorbs the cost of uninsured when they have no place else to go. Rural facilities are eligible to receive additional money to help mitigate these problems.

A study from 2021-2022 listed the top 20 problems that rural facilities are facing now. Here are the top 3 in order:  mental health and mental disorders, addiction, and healthcare access & quality.  We already know there is a shortage of acute psychiatric beds to which we can transfer patients. So, we hold them longer in the EDs. We know that substance abuse problem is not going away anytime soon. We know that chronic illnesses are on the rise and there are not enough community primary care providers. All this means you and I will continue to see an increase of these patients in the ED. We need every available EM provider to handle this tall task.

The Good Stuff

A quick read about Lauren, an NP, who donated a kidney to her dad. I know this is done numerous times every year by all kinds of folks. They are all heroes; just like Lauren.

Congrats to the Bryant University Physician Assistant Class of 2023. They raised about $40,000 for the Amercian Heart Association and another $8,000 for a low-income clinic where they also provided free health care to low-income clients. Imagine the impact they will have as the next generation of providers!

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