Democratic Group Practice Section Newsletter - May 2011
From the Newsletter Editor - Democratic Group Practice Section Newsletter, May 2011
Savoy Brummer, MD
Included in this issue are responses that represent a cross spectrum of physicians answering the question, “what does a democratic practice model mean to me.” It was a purposefully open ended question that was given to physicians across the country to hear each of their unique perspective of democratic models and how it relates to their particular regions. It seems as if each of us has a story to tell and here are some of our responses.
I choose a regional, single owner group after finishing my residency and I made a good living. However, the practice was not a particularly fulfilling professional experience. Participation was not universally allowed and nepotism and seniority were the rule and not the exception. I wanted more out of my particular career and believed that administration could possibly offer me a greater sense of fulfillment. I was soon given an unlikely opportunity to become the medical director of several emergency departments managed by a large publicly traded EM group. I did well and with that role I was offered greater access to information. I started to understand how this corporation practiced the business of medicine and that they valued philosophical and financial interests of the shareholders and Wall Street above those of their practicing physicians.
I also learned how mega-groups targeted the very few democratic and independent groups in the area. The leadership of the organization told me that democratic groups were a threat to their organization and it was their goal to completely eliminate those groups. They and other large groups started acquiring democratic and smaller independent groups underbidding for subsidies with administration just to remove that threat.
I felt like I had to make a change and allowed myself to be open to other opportunities. I received an unlikely phone call from a democratic group out West that offered me in fact a different practice model—a democratic model. The President told me that the company was to be whatever its providers wanted it to be. He gave me only one limitation which was to “treat the company like it was your own.” That was a complete 360 from before and I soon realized that the company was fair and egalitarian. The expectation was that everyone would contribute and accountability was privilege and not a responsibility.
But I also realized democracy wasn’t pretty. I soon found out that our shareholder meetings were like the British House of Commons—I swear I saw a beer bottle fly out of someone’s hands one time. However after the rancor and dissent, there was a vote and the business of the company was conducted. I disagreed with the President and the Board and the shareholders on all kinds of issues, but in the end I had a voice. I learned that being equal and being fair are two different ideas, but if you pursue one you are likely to achieve both.
Out West I did see a different paradigm for this model as democratic groups had a presence. Residents seemed to have greater options regarding the type of practice and actively choose democratic groups. Administrators also seemed to appreciate the gravity and importance of democratic groups out in this region because there was a history and presence larger concentration of democratic groups.
I felt that the understanding of our practice model was largely absent in the Southern US. Large one owner groups and publicly traded entities squeezed physicians out of their own practices. My group realized that there was a need to increase the presence of our philosophical groups in the South. We started with really little to no name recognition or marketing and extended our presence there. Unexpectedly, we were greeted with a warm reception by ACEP docs, chairmen of academic emergency departments, and even CEO’s from non-democratic independent EM groups who realized that their peers and communities really deserved the option of a democratic practice model. Other democratic groups have seen this need as well, and I truly hope that our mutual success will together build a democratic presence in the South and across the rest of the country.
Are We Winning or Losing? - Democratic Group Practice Section Newsletter, May 2011
Ronald A. Hellstern, MD, FACEP
I have recently been asked to work with several of the University of Texas Southwestern Medical School EM residents and fellows who are currently engaged in collecting data on all ED staffing contract holders in Texas in an effort to conduct a longitudinal study of contract turnover. Texas is a good state in which to do such study since it has nearly 20% of the EDs in the country with a disproportionate number of them rural and small volume – a prime market segment for the large, national contract management groups. Some of the questions to be answered by the study are:
- Are the large contract management groups gaining overall market share (as it seems anecdotally) or just swapping around contracts?
- If they are gaining market share, at whose expense?
- Are independent groups losing market share (as it seems anecdotally), and if so, to what alternate ED staffing models?
The study cannot, of course, measure “democracy” in independent groups – our Section even struggles with how to define it – but only independence per se.
The issue is increasingly clouded by a variety of hybrid models. Historically it’s been estimated that approximately 1/3 of EDs were staffed by independent groups, 1/3 by large contract management groups and 1/3 as hospital employees, though even this breakdown is muddied by how to classify the large physician-owned regional contract management groups – are these independent groups or large contract management groups?
Healthcare reform has clearly given impetus to hospitals seeking to acquire their emergency physicians and make them employees, but in some cases the hospital contracts with an EM practice management entity to manage the practice. Where do these fit?
And what about the independent groups managed by medical service organizations? They are independent but with large contract management group caliber management sophistication.
If anyone has thoughts about such a study and what questions it might address if you would send them my way I will be happy to pass them along.
Everything but the Lamborghini - Democratic Group Practice Section Newsletter, May 2011
Evan Cohen, MD
When I first started my job search, I had in mind an advertisement I had seen as a kid for “the right job.” Come in late, leave early, two hour lunches, company Lamborghini and sexy assistant included. However, when I was reminded that I was applying to an emergency medicine job and not one in dermatology, I decided to rearrange my priorities.
After an extensive search, I realized that there is no perfect job. If you had lots of time off and low patient volume, or want to roll out of bed and walk to work in Union Square, you will make less money. If you want to make a million dollars, you had better be willing to work the night shift on New Year’s Eve in Juno.
I searched far and wide looking for that “right job.” I came across three basic types of jobs in emergency medicine. You can be a hospital employee, work as an independent contractor or work with a democratic group. I found the most advantages with the democratic group structure and found it to be like a large pool of emergency doctors working for the interest of the group.
The group contracts to different hospitals around a region and the country to run their emergency departments. If the group does a good job, they get to renew the contract. The more contracts and the better each emergency department performs, the better off everyone in the group is. A larger group with a central administration, billing, and I.T consultants may equal more efficiency. On a selfish level, this creates a system which makes doctors more efficient. With scribes, a uniform EMR, a HR department that works exclusively with emergency physicians and a billing company, this means that I can spend most of my day only worrying about patient care. The system makes me more efficient, patients are happier and I enjoy the job more.
In a job where it is so easy to clock in and out and have so little to do with the environment in which you are surrounded, this practice opportunity allowed me to get a team oriented experience at my job. I am connected with the other doctors in the practice and we work towards common goals.
While I may have not gotten lots of corporate “buy in” on the company Lamborghini, a truly democratic group has afforded me real job satisfaction, a feeling of working towards a common goal and some piece of mind that I am being fairly compensated for the value that I bring to my job.
Emergency Medicine Action Fund Announced - Democratic Group Practice Section Newsletter, May 2011
ACEP's New grassroots effort aims to influence health care reform’s regulatory implementation. With changes in the health care system already underway, a new initiative is looking to positively impact the regulations that will be written and implemented under this sweeping reform.
The Emergency Medicine Action Fund, launched by ACEP in February, will pool contributions from individual emergency physicians and groups, ACEP Sections of Membership, and anyone else interested in advancing emergency care to provide financial support for advocacy activities in the regulatory arena. “This is probably the most important, defining moment for emergency medicine in our lifetime,” said ACEP President Dr. Sandra Schneider. “The decisions that are made now will set the course for us for years to come and we must positively influence the regulatory agenda. This Action Fund will help us do that and create a practice environment we can thrive in.”
The Emergency Medicine Action Fund will pursue a regulatory agenda that supports emergency physicians and quality emergency care. For example, evolving practice models and demonstration projects, such as accountable care organizations and bundled payments, are two areas of the Patient Protection and Affordable Care Act where the Action Fund might be able to wield some influence. “We need to be out there with the rule writers, working to ensure that emergency medicine’s perspective is valued,” said Dr. Angela Gardner, ACEP Past President who first proposed a national grassroots initiative focused on federal regulatory affairs. “It is critical that we be involved in these decisions regarding the formation of the future of health care delivery. This is our opportunity to be part of it.”
The following organizations have been invited to designate representatives to the initial Board of Governors – American Academy of Emergency Medicine (AAEM), Association of Academic Chairs of Emergency Medicine (AACEM), American College of Osteopathic Emergency Physicians (ACOEP), Emergency Department Practice Management Association (EDPMA), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM).
One of the unique features of the Emergency Medicine Action Fund is that multiple Sections can band together to form coalitions that would be eligible to have a seat on the Board of Governors. Or Sections can organize their individual members for collective representation. The first 10 groups of contributors at $100,000 will be granted seats on the Action Fund’s Board of Governors.
“We are encouraging Sections, chapters and small to mid-sized groups to combine their resources,” Dr. Schneider said. “This is intended to be an inclusive effort, and everyone’s contributions are needed.”
The Emergency Medicine Action Fund is modeled on a successful initiative sponsored by CAL/ACEP, CAL/AAEM, EDPMA, and rural emergency physicians in California that has raised several million dollars for state advocacy since 2004.
Wes Fields, chair of the California Emergency Medicine Advocacy Fund, said their program doubled the size of the CAL/ACEP advocacy staff, increased the number of lobbyists and consultants, and engaged in legal activities related to physician payment practices. He has been appointed by Dr. Schneider as the founding chair of the new national Action Fund.
“I view this as the best form of free speech on behalf of emergency physicians and our patients,” Dr. Fields said. “It is not partisan. It is not political.
“The rule writers and the policy makers will hear emergency medicine speaking with one voice, with one set of goals, one approach,” he added. “We need wide and deep support, even from those who are not members of the College.”
Activities planned by the Emergency Medicine Action Fund are intended to enable participants to make contributions that would be tax-deductible business expenses (tax deductibility can be determined only by participants’ tax advisors).
NEMPAC, the National Emergency Medicine Political Action Committee of the ACEP, gives contributions to candidates who have listened to the needs of emergency medicine and made a positive change. However, NEMPAC may be used only to support candidates.
The Action Fund can enhance regulatory advocacy with policy makers to ensure emergency physicians receive fair payment for their services. It can also fund numerous meetings with regulators to help guarantee that patients receive the best care, and provide funding for studies to demonstrate the value of emergency medicine.
“With the new Congressional session upon us, it is as important as ever to be active on both the legislative and regulatory fronts,” Dr. Schneider said. “We will depend on all of these funds to make our case. This will be the year we ask everyone to dig a little deeper. In these challenging times, we need contributions to both the Action Fund and NEMPAC.”
Find out more about the Emergency Medicine Action Fund at www.acep.org/EMActionFund.
Journey - Democratic Group Practice Section Newsletter, May 2011
Michael Bessette, MD, FACEP
My journey to a democratic group practice had many stops along the way. I tried a wide variety of work arrangements, some good, some not so good. My needs and desires changed as I matured and traveled. I am very happy that I am currently partnered in a successful and well-managed democratic group.
As I finished residency, my academic chairman landed a new contract. The site sounded interesting and I became an academic employee. I quickly advanced my administrative career. A few years later, I decided to move to the west coast. There, I tried my hand at independent contractor work. The money was good, compared to academic work, but there was very slim chance of advancement to an administrative position. After a few years, I moved back to the east coast and into a great single-hospital democratic group with an associate director title. In two years, I made partner and was promoted to director. Life was good, until the hospital was sold to a new owner. Suddenly, our contract was sold out from under us, and there was no more group.
Very quickly thereafter, I was lucky enough to be hired by a large, multi-hospital, democratic group. Through this group, I have been able to find career stability with opportunity for advancement. I am now in a director position at a large urban hospital. I made partner exactly as was guaranteed in my contract and enjoy the support of a talented team of fellow physicians. It took me several years to recognize my perfect career. I am thrilled that I have found it.
Way Closer to Perfect - Democratic Group Practice Section Newsletter, May 2011
Deonza Thymes, MD
When I finished residency, I knew I would get a job but I never thought about the type of EM group I would work with. I knew you could be an employee or an independent contractor. I had no idea about partnership tracks or democratic groups. Honestly I am not sure I cared that much until very recently.
After working with my group for a couple of years I began thinking about how I had never met any of the people whose names were on my check. Never been invited to a group sponsored event such as a Christmas party or annual meeting. Odd?? maybe, what do I know? It was my first real ER job. I just thought that was how the world of emergency medicine functioned, especially when you are an independent contractor. We are basically loners; when it comes to work anyway. You try to get along with the Docs you work with and maybe, if you are lucky, forge a friendship.
I did not know what a democratic group was until a couple of months ago. With my prior group I went to work, got a paycheck and an occasional bonus. I had some desire to pursue a leadership role but I was not really sure where to start. I would ask around but not really get much in the way of direction. At times, I would think to myself, “Maybe, I’m just not putting forth enough effort to be involved. The other possibility is that they mailed my decoder ring to the wrong address. I guess, that’s unlikely, decoder rings are so 1980. Truth is, no opportunities were presented.
Recently, I became part of a different EM group. A democratic group. The difference was apparent before I even officially joined the group. I met the President and Vice-President of the group. I mentioned that I did not feel as if there was significant opportunity to be involved on a deeper level with my old group. From that point on, I not only have been made aware but have been encouraged to become more involved. I have only been with the group for a couple of months and I have already been appointed to a committee whose focus is to integrate physician services. I have been told of opportunities for potential medical director positions among other things. For me the most notable aspect is that they are reaching out to me.
In my new group, I don’t feel like I am a hired hand. I feel as if my opinion and contributions are needed and valued. In short, I feel as if I can have a piece of the success of the group as opposed to working just to make the owners of the group successful. My new group seems to care about its docs and making sure that our hard work comes back to benefit us. This is evident by their stock purchasing policy. One can only purchase stock if you are actively working. No public trading, no retired guy or business man collecting money off of us toiling all night in the ED.
Am I still in the honeymoon phase? Probably. Is my new group perfect? No! But I for one realize that there is no such thing as perfect. I can tell you this, my new group is a lot closer than my last one. IMHO
The Good, the Bad, and the Ugly - Democratic Group Practice Section Newsletter, May 2011
Jessica Sims, MD
I was recently asked to share what democracy in emergency medicine means to me as it relates to the West Coast. It is a topic that I have given much thought to over the years. I believe most would agree that democracy is a noble aspiration, and even more impressive when it succeeds and manages to pay a competitive wage. It is easy to understand how EM groups with non-democratic practice models have maintained such a strong grip on the industry. The weakness inherent in collaborative decision making allows these businesses to pit actual earnings against noble ideals when recruiting and retaining physicians. In Southern California, large non-democratic companies are like machines engaging hospital administrators, pursuing contracts, and paying physicians top dollar when necessary for their survival. There are no cumbersome votes on any level with the emphasis on quickly and efficiently accomplishing goals. There is however, notable absence of fairness, security, career longevity, and empowerment for physicians within the rank and file.
I am continually impressed that democratic groups are able to effectively compete. This alone speaks volumes to the dedicated individuals who form and steer democratic groups large and small.
To some this discussion may seem an ambiguous waste of time. Democracy is time consuming and messy. However, it is transparent in all of its grandeur and it’s ugliness. One size does not fit all. For many docs this simply is neither practical nor convenient. There are many emergency physicians who agree with the idea of democracy, but for practical reasons are unable or unwilling to join ‘democratic’ groups. Even academic Emergentologists find it difficult to practice democracy within their own ranks although in theory they almost universally support the concept.
For most of us in Southern California, a career in EM boils down to freedom, convenience, and security. We want to walk away from a shift and not look back and expect to be well compensated. The very existence of a hospital based practice, such as EM, requires relationship building (often with people whom nobody would ever want a relationship), fielding complaints and challenging goals with diplomacy, acquiring and sustaining competitive contracts, minimizing losses, mitigating lawsuits, and so on. Let’s not forget there are also patients to be seen. Democracy implies each physician to be accountable for these responsibilities. It is no wonder many West Coast doctors are willing to sell their talent and their voice for a simple life, high hourly wage, and just hope for the best.
I am left wondering what happens here on the West Coast in 10 years or in 30 years if EM groups not owned by the majority of their practicing physician continue determining career paths for so many doctors. What happens if these groups out compete democratic groups and control not only employment, but also represent hundreds or thousands of us to ACEP, the AMA, and in governance? If we want doctors to join and participate in democratic groups, it must be practical and profitable for them to do so. Organizing and streamlining democratic group practices is the only way I can imagine achieving this. In my opinion this means democratic minded groups need to be on the forefront of ideas and technology that make the practice of medicine, business, and democracy as convenient and efficient as possible. The question is how democratic practice models tap into our unique strengths to rival the efficiency inherent in autocracies. When that happens, democracy in emergency medicine will be a true force to be reckoned with.