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Sounding another alarm
Editorials
Sounding Another Alarm As one of the “pioneers” who dared to promote emergency medicine as a specialty more than 2 decades ago, and a charter member of the American College of Emergency Physicians (ACEP), I have been content to write, develop academic emergency medicine, and work in clinical emergency medicine while witnessing with pleasure the growth of the field and the exciting and capable residents entering the specialty with enthusiasm and pride. Recently, however, I have witnessed an insidious cancer beginning to dominate the specialty of Emergency Medicine and strangling its development. This disease is the blight of exploitative multihospital contract groups. It is time to sound an alarm. These contract groups eliminate physician’s rights and create a second-class specialty. Have we worked so diligently for many years only to create a cadre of migrant hourly workers to be exploited by unethical and immoral contract management groups? In what other specialty can a minor disagreement with an administrator result in virtually immediate termination within a day? In the contract of more than one such group, the physician gives up all medical staff rights to due process or a reasonable hearing before peers. The vice president of one such group recently acknowledged in a deposition that because he provides the physician with the “ticket” to practice the “trade” (emergency medicine), he can take it away. This deposition also showed restrictive covenants in a peculiar and destructive light, eliminating the physician from practicing in the hospital emergency unit, if, for any reason, the group loses the contract. Thus, the professional relationship with a hospital and a community can be broken for the physician after many years simply because the contract management group loses a contract-even if it is for their corporate incompetence. In this framework, it becomes clear that exploitative contract management groups are destroying the freedom of emergency physicians to practice. Offering in most cases little more than scheduling, these groups often compel the physician to give more than his entire income to the corporation, ie, if the physician earns two dollars, he must give the group one dollar. For the “privilege” of being exploited, professionalism and peer respect are diminished, as are job security and any relationship with a hospital. The lack of due process, or any safeguards usually accorded physicians, are lost to the whim of an irate administrator. In one case, the corporate officer-in-charge admitted that physician contracts are written to provide for immediate termination, without cause or recourse, at the hospital’s request. Such noncompete clauses remove all usual physician rights of due process and show careless disregard for the physician’s career, suffocating the field of emergency medicine to which many of us have devoted decades of work. And what about quality? Such contract groups have a 254
“slot” to fill in a schedule. In cases in which a shift is empty, quality is frequently sacrificed to keep the schedule filled. The system is exploitative for the physician and dangerous for the patient. One further danger occurs when groups “go public” on the stock exchange. Shareholder satisfaction is now pitted against quality of care and physician well-being. Wall Street likes these stocks as long as they perform financially. Emergency physician exploitation is not a particular concern to brokerage houses and financial analysts, nor is quality unless it impacts the “bottom line.” Tracking the money of one recent company that has gone public allows a view of “big business” generated from emergency physician’s fees. The clinical practitioner and the patient become lost as clinical practice serves thousands of stock-holders with secondary concern for patients. Following the money trail is a time-honored and accurate way to pass through levels of rhetoric and arrive at the truth. Recently, a management group went public with a little more than 13 million shares. This company is now traded on the NASDAQ (the over-the-counter stock exchange). Of these shares, approximately 8 million went to the operator of the group. Based on the current stock price, this immediately made his worth more than 300 million dollars, putting him on the Forbes 400 list of the wealthiest Americans. Other insiders received close to 2 million shares, leaving approximately 3 million for the public shareholders. Earnings per share were close to $1 .OO,and the company has a price to earnings ration of close to 40. In October 1993, the company issued a “secondary offering” of 2.5 million shares that are designed to generate an additional 75 million dollars to allow further acquisitions and other activities. The company has its own billing company, and its own insurance company. The company has recently acquired another contract management company for emergency departments. Revenues in 1993 approach $500 million. Should the ACEP be concerned about the suffocation of the field and the destructive effects on physicians and patients? The apparent indifference of ACEP is striking. Can it be explained by the past presidents (as well as many on the roster of the board of directors, past and present), who are associated with large contract holders? (The past president, the current vice president, and the vice speaker are deeply involved with large contract management groups.) ACEP’s inactivity encourages the belief that it is beholden to the contract groups. Our professional organization’s silence has encouraged a phenomenon and process destructive to the specialty of emergency medicine and opposed by a vast majority of its members.*
‘One recent study conducted by Scott Plantz, M.D., took 1,000 emergency physicians from the American Medical Association
EDITORIALS
Unless aroused by this threat to emergency physicians and emergency medicine, the ACEP may cease to be the voice of the emergency physician in the future. (Even now, a new group, The American Academy of Emergency Medicine (AAEM) has been increasing its membership rapidly.) Because the ACEP is structurally a nondemocratic organization, the will of the majority of members cannot effectively change the destructive course of ACEP. The health care system in the United States is now being reviewed in Washington, and there has been a widespread belief that larger corporate entitites can effectively “manage” medical care more effectively. In emergency medicine, we have fostered exploitative companies destructive for physicians and deleterious to the quality of care given to patients in emergency departments across the nation, which
(AMA) list of emergency physicians and discovered in his survey that 91% of the emergency physicians who responded did not wish to work for a multihospital contract group. (The AMA list was used because ACEP did not make its membership list available to be polled on this issue.)
255
are all orchestrated through a costly additional level of nonproducing “middlemen.” The practice of emergency medicine is not a “free enterprise system” analogous to a factory in which the workers not only receive less income than the bosses, but are given a job in the owner’s factory. This analogy is critically flawed. These multihospital groups have not invested in the physician’s education. The hospital provides the emergency department facilities. The group provides scheduling. It is the physician who is the intellectual and mechanical “factory” creating the “product.” In many cases, these contract management groups schedule and take none of the responsibility for patient care. This exploits patients, physicians, and hospitals. We must tight these medical marauders who are debilitating our specialty, decreasing quality, impairing physician autonomy, and eliminating our rights and access to due process. Finally, we need to scrutinize the role of our professional organizations who have opened the door to these pirates and made them welcome in the house of emergency medicine. GEORGER. SCHWARTZ, MD Santa Fe, NM
Sounding Another Alarm As one of the “pioneers” who dared to promote emergency medicine as a specialty more than 2 decades ago, and a charter member of the American College of Emergency Physicians (ACEP), I have been content to write, develop academic emergency medicine, and work in clinical emergency medicine while witnessing with pleasure the growth of the field and the exciting and capable residents entering the specialty with enthusiasm and pride. Recently, however, I have witnessed an insidious cancer beginning to dominate the specialty of Emergency Medicine and strangling its development. This disease is the blight of exploitative multihospital contract groups. It is time to sound an alarm. These contract groups eliminate physician’s rights and create a second-class specialty. Have we worked so diligently for many years only to create a cadre of migrant hourly workers to be exploited by unethical and immoral contract management groups? In what other specialty can a minor disagreement with an administrator result in virtually immediate termination within a day? In the contract of more than one such group, the physician gives up all medical staff rights to due process or a reasonable hearing before peers. The vice president of one such group recently acknowledged in a deposition that because he provides the physician with the “ticket” to practice the “trade” (emergency medicine), he can take it away. This deposition also showed restrictive covenants in a peculiar and destructive light, eliminating the physician from practicing in the hospital emergency unit, if, for any reason, the group loses the contract. Thus, the professional relationship with a hospital and a community can be broken for the physician after many years simply because the contract management group loses a contract-even if it is for their corporate incompetence. In this framework, it becomes clear that exploitative contract management groups are destroying the freedom of emergency physicians to practice. Offering in most cases little more than scheduling, these groups often compel the physician to give more than his entire income to the corporation, ie, if the physician earns two dollars, he must give the group one dollar. For the “privilege” of being exploited, professionalism and peer respect are diminished, as are job security and any relationship with a hospital. The lack of due process, or any safeguards usually accorded physicians, are lost to the whim of an irate administrator. In one case, the corporate officer-in-charge admitted that physician contracts are written to provide for immediate termination, without cause or recourse, at the hospital’s request. Such noncompete clauses remove all usual physician rights of due process and show careless disregard for the physician’s career, suffocating the field of emergency medicine to which many of us have devoted decades of work. And what about quality? Such contract groups have a 254
“slot” to fill in a schedule. In cases in which a shift is empty, quality is frequently sacrificed to keep the schedule filled. The system is exploitative for the physician and dangerous for the patient. One further danger occurs when groups “go public” on the stock exchange. Shareholder satisfaction is now pitted against quality of care and physician well-being. Wall Street likes these stocks as long as they perform financially. Emergency physician exploitation is not a particular concern to brokerage houses and financial analysts, nor is quality unless it impacts the “bottom line.” Tracking the money of one recent company that has gone public allows a view of “big business” generated from emergency physician’s fees. The clinical practitioner and the patient become lost as clinical practice serves thousands of stock-holders with secondary concern for patients. Following the money trail is a time-honored and accurate way to pass through levels of rhetoric and arrive at the truth. Recently, a management group went public with a little more than 13 million shares. This company is now traded on the NASDAQ (the over-the-counter stock exchange). Of these shares, approximately 8 million went to the operator of the group. Based on the current stock price, this immediately made his worth more than 300 million dollars, putting him on the Forbes 400 list of the wealthiest Americans. Other insiders received close to 2 million shares, leaving approximately 3 million for the public shareholders. Earnings per share were close to $1 .OO,and the company has a price to earnings ration of close to 40. In October 1993, the company issued a “secondary offering” of 2.5 million shares that are designed to generate an additional 75 million dollars to allow further acquisitions and other activities. The company has its own billing company, and its own insurance company. The company has recently acquired another contract management company for emergency departments. Revenues in 1993 approach $500 million. Should the ACEP be concerned about the suffocation of the field and the destructive effects on physicians and patients? The apparent indifference of ACEP is striking. Can it be explained by the past presidents (as well as many on the roster of the board of directors, past and present), who are associated with large contract holders? (The past president, the current vice president, and the vice speaker are deeply involved with large contract management groups.) ACEP’s inactivity encourages the belief that it is beholden to the contract groups. Our professional organization’s silence has encouraged a phenomenon and process destructive to the specialty of emergency medicine and opposed by a vast majority of its members.*
‘One recent study conducted by Scott Plantz, M.D., took 1,000 emergency physicians from the American Medical Association
EDITORIALS
Unless aroused by this threat to emergency physicians and emergency medicine, the ACEP may cease to be the voice of the emergency physician in the future. (Even now, a new group, The American Academy of Emergency Medicine (AAEM) has been increasing its membership rapidly.) Because the ACEP is structurally a nondemocratic organization, the will of the majority of members cannot effectively change the destructive course of ACEP. The health care system in the United States is now being reviewed in Washington, and there has been a widespread belief that larger corporate entitites can effectively “manage” medical care more effectively. In emergency medicine, we have fostered exploitative companies destructive for physicians and deleterious to the quality of care given to patients in emergency departments across the nation, which
(AMA) list of emergency physicians and discovered in his survey that 91% of the emergency physicians who responded did not wish to work for a multihospital contract group. (The AMA list was used because ACEP did not make its membership list available to be polled on this issue.)
255
are all orchestrated through a costly additional level of nonproducing “middlemen.” The practice of emergency medicine is not a “free enterprise system” analogous to a factory in which the workers not only receive less income than the bosses, but are given a job in the owner’s factory. This analogy is critically flawed. These multihospital groups have not invested in the physician’s education. The hospital provides the emergency department facilities. The group provides scheduling. It is the physician who is the intellectual and mechanical “factory” creating the “product.” In many cases, these contract management groups schedule and take none of the responsibility for patient care. This exploits patients, physicians, and hospitals. We must tight these medical marauders who are debilitating our specialty, decreasing quality, impairing physician autonomy, and eliminating our rights and access to due process. Finally, we need to scrutinize the role of our professional organizations who have opened the door to these pirates and made them welcome in the house of emergency medicine. GEORGER. SCHWARTZ, MD Santa Fe, NM