Game of Thrones
Also: More AI in EM; PA burnout; financial health of hospitals; and...the best for last.
Top of the Week
The cast
Private Equity wants to have as many profitable EM contracts as possible. They want to pay the least costs (labor being the biggest) as possible. They want to collect the highest profits possible.
CMG’s want to maximize profit margins by maximizing billable RVUs and minimizing labor costs. They have increased EM NP & PA employment at about 1/3 the cost of an EP, but with the ability to bill 80%+ of an EPs charge. Where do the savings go?
Hospitals want their ED waiting rooms cleared. They want good throughput times, positive patient reviews, and satisfactory admission rates (not transferring patients out). They want to minimize labor costs of nursing and all other ancillary employees. When they can, some hospitals will try to slide more tasks, responsibilities and liabilities on to EM providers in order to replace that which the hospital will no longer pay for or supply. For example, some hospitals are not paying competitive rates to attract and retain nurses? Some hospitals contract with bargain basement radiology groups that do not adequately support the ED, especially during overnight shifts.
EPs want real support (not just lip service) from their employers and hospital partners. When EPs work with EM NPs & PAs they want their education and training to appropriately match the needs of the ED. EPs want to be adequately compensated for the risk they assume (this includes NP & PA supervision). They want to share in the wealth they generate for CMGs and PE investors. Some EPs feel that there are too many EM NPs & PAs in the ED, and that their current scope of practice needs to be narrowed. Some EPs feel that they should establish education and training standards for EM NPs & PAs.
EM NPs & PAs want to responsibly practice at the top of their respective licenses in EM in order to increase patient access to quality EM care, and in order to bring real value to the EM provider team. They want responsive EP close supervision when they ask for it. They want to continue to learn. They want to be adequately compensated for the risk they assume. This includes the high acuity that gets thrown their way in busy EDs. They want to share in the wealth they generate for CMGs and PE investors.
ED patients just want to be seen in a reasonable amount of time. They want to be seen by any qualified provider who can evaluate and manage their medical problems. At the minimum, they want to encounter any qualified provider who can at least initiate evaluation & management with some initial diagnostic tests and therapeutics.
When its right, its right
First, let me say that I don’t mean to paint a picture that conditions are less than satisfactory everywhere. I was fortunate enough once to work for a small, local CMG who paid $4000/year for cme. They also matched 100% of our 401k contributions, and we were immediately vested. This was largely the influence of a very smart CFO who understood that it was good business to re-invest profits in the workforce. Retention was great! Yet another CMG, who was provider owned, once paid us very generous 5-digit profit sharing distributions 10 months after the host hospital cancelled their contract. There are still desirable employers out there, for sure. However, there’s lots of inequity now between those who produce profits vs those who collect them.
Let them eat cake
Though I fully understand the following is an apples vs oranges comparison, I think it’s a timely illustration of the division between labor and those at the very top. In 1969 America, the ratio of average CEO pay to average employee pay was about 20:1. Today, the ratio of General Motors CEO pay to the average GM worker pay is 365:1. Is it a wonder why folks are ticked off? How much of the revenue that you produce should go to the CMG…to PE; how much should come back to you.?
Where did all go wrong? Check out this very interesting piece that discusses CMGs’ role in the current state of affairs. There is no question that there definitely exists a disconnect between EM labor and entities that collect the profits which EPs, EM NPs & PAs generate. A 2020 ProPublica article also covered this profit-sharing disparity. One additional element of this problem’s evolution deserves particular attention.
Years ago, when the money was good for everybody, utilizing EM NPs & PAs (at a lower cost) generated attractive profits that sometimes were used in part to bump EP payrates; but they were used mostly to build the wealth of CMGs and PE. So, well-intentioned EM NPs & PAs went to work and saw as many patients as they could. Some were thrown into unfair high acuity situations with insufficient EP supervision. Others developed their knowledge skills and abilities through trial by fire. They helped decompress EDs. They became valued co-pilots on overnight shifts. They helped to invent “Waiting Room” medicine. They worked in remote locations when an EP could not be recruited. Though EM NPs & PAs generated considerable profits, they disproportionately received the least share. Now they face a growing movement which is working to limit their presence and their scope of practice in the ED.
The Battle of Blair Mountain
Conditions in the ED are not well. Providers depend on a department adequately staffed with nurses, but nurses are victims of burnout themselves. Trying to protect nurses with nurse-patient ratios is facing opposition.
Physicians are beginning to organize. In New York City, resident physicians staged the first strike since 1990.
In Minnesota, over 550 physicians and other healthcare providers have taken official steps to unionize and become the largest private sector of US clinicians.
In Oregon and Washington, over 4000 healthcare workers agreed to a late September strike if demands are not met.
Lots of money is up for grabs in EM. Everybody wants it, but who is deciding what the fair shares are for whom? It is time that EM providers coalesce and consolidate the power they already intrinsically have: they are the producers of EM revenue! Get your fair share of what you produced.
Emergency Medicine
AI to the rescue
How many times this year did you have to push a consultant to admit your ED patient? Connecticut physicians are working with MIT students to develop solutions to identify which patients need to be admitted.
AI vs the EM provider
In April 2023 an emergency physician tested ChatGPT at diagnosing lower abdominal pain in a female. The AI did pretty good but failed to consider ectopic pregnancy. We were told, however, that AI would continue to learn at rapid speed. A new study published by European Society for Emergency Medicine (EUSEM) takes another look comparing ChatGPT and EPs.
The return of the ED patient
Canada is seeing a return of ED patient volume, but exactly which kind of patients are they? This article takes a look at this well as the effects on ED planning, and EP stress level.
House of Medicine
More detail on PA burnout
Andrzej Kozikowski, PhD, of the National Commission on Certification of Physician Assistants in Georgia, and colleagues published interesting details of PA burnout. Notable findings
8% of PAs were planning their exit within the next 12 months
burnout was more likely for “those working in critical care medicine or emergency medicine versus primary care; older than age 35; and worked in New England, Mountain, or the Pacific Census Division versus the South Atlantic…”
Closing gaps
Growing up, I recall how the microchip and the internet greatly impacted our lives and paved roads for rapid development of other tech that continues to change our lives now. In medicine, we will continue to see trends of closing the gap between stakeholders in healthcare delivery. Take a look at this example.
Duty to report
Read this concerning article about a Utah hospital that has been alleged to dissuade healthcare workers to report sexual and physical abuse by staff on patients.
More steps to protect the work force
Violence against healthcare workers has been well documented. A large number of states have passed legislation to address this. An Oregon hospital is taking steps to further protect healthcare workers after concerning episodes of violence.
How to keep talent in the group
There are some job-related external conditions that employers cannot control. However, they should fully exert efforts on the things they can control. Check out this quick read on how to retain good employees.
Hospitals, Health Systems, and More
The struggle is real, but some are doing ok
Money continues to be tight for many hospitals. “The current economic situation” remains an important concern for CFO’s. Four more hospitals close in Texas, while another hospital sets up a GoFundMe account. However, checkout these financial report cards for other profitable health systems.
An alternative to Locums
Managing healthcare labor has become increasingly challenging. Labor shortages, and burnout require new problem-solving approaches that address the needs of a diverse workforce. Check out this approach.
Is private equity having second thoughts?
With the failure of Envision and American Physician Partners, there has been even more scrutiny of PE in healthcare. An advisor to PE shares insight into how some PE groups may be changing their tune.
The Good Stuff
I believe EPs, EM NPs, and EM PAs all have more in common than they have differences. EM providers are paying off school loans, car loans, mortgages, or maybe buying their first home. They’re trying to save for their own retirement, and their kids’ college funds. They’re trying to preserve precious time to spend with significant others, family, and friends. They’re trying to make appearances to their kids’ athletic events, and other special school events. All EM providers are trying to provide efficient quality healthcare while being asked to do more with less. I believe that in EDs all across America we’re working well together and getting along just fine.
I don’t believe EM NPs & EM PAs desire to replace EPs. They just want to help see patients in the ED. NPs and PAs are only increasing in numbers. The Bureau of Labor and Statistics projects a 27% job growth for PAs from 2022-2023. They project a 40% job growth by 2031 for NPs.
A recent 2022 study by NCCPA & SEMPA report that over 14,000 PAs practice in EM. The Advanced Emergency Nursing Journal reported that over 17,000 NPs practice EM. EM NPs & PAs can help increase patient access to quality EM care.
It is best for EM NPs & PAs to chart the course of their own respective professions’ futures, rather than allow others to do it for them.
To all the EM NPs & PAs who have sacrificed money, time, mental & physical wellness to take care of patients in the ED: thank you. You are the Good Stuff!
I want to sincerely thank you for reading the EM NP & PA Workforce Newsletter. Unfortunately, this will be the last edition. Due to military obligations, I will be away for a substantial amount of time. It has been a privilege to try to help raise awareness and offer perspective to issues affecting your profession.
This newsletter has been sponsored by Ivy Clinicians, the simplest way for emergency physician assistants, and nurse practitioners to find jobs they love.
Please check out the EM NP & PA Workforce podcast here.