Cut-throat Contract Wars in EM

docB · Jan 6, 2007

This is a series of articles about a situation in a small North Carolina town where a group of EPs lost their contract to a corporate group. It's got lots of controversy and bad blood and it's being played out in the press. Interesting for those who think EM doesn't have a cut-throat business side to it.

http://www.themountaineer.com/archives/2006/12/04/topstories_erdocsoutnewfirmin.html
http://www.themountaineer.com/archives/2006/12/20/topstories_emergencydocsmeetwit.html
http://www.themountaineer.com/archives/2006/12/25/topstories_newphysicianstobegin.html
http://www.themountaineer.com/archives/2006/12/29/topstories_edswitchmade.html
http://www.themountaineer.com/archives/2006/12/22/topstories_hospitalboardstaysth.html

WestcoastMedicine · Jan 6, 2007

http://www.aaem.org/rem/The_Rape_of_Emergency_Medicine.pdf

This short, but interesting read, talks about many of the same topics.

ForbiddenComma · Jan 6, 2007

Phoenix will provide six full-time doctors to replace the nine full-time and three part-time doctors currently employed at the emergency department. Their schedules will provide staffing comparable to what Haywood Emergency Physicians have offered, Lutes said.

Did I fail my remedial arithmetic class, or does this guy directly contradict himself within two sentences?

denied · Jan 6, 2007

docB said:
This is a series of articles about a situation in a small North Carolina town where a group of EPs lost their contract to a corporate group. It's got lots of controversy and bad blood and it's being played out in the press. Interesting for those who think EM doesn't have a cut-throat business side to it.

http://www.themountaineer.com/archives/2006/12/04/topstories_erdocsoutnewfirmin.html
http://www.themountaineer.com/archives/2006/12/20/topstories_emergencydocsmeetwit.html
http://www.themountaineer.com/archives/2006/12/25/topstories_newphysicianstobegin.html
http://www.themountaineer.com/archives/2006/12/29/topstories_edswitchmade.html
http://www.themountaineer.com/archives/2006/12/22/topstories_hospitalboardstaysth.html

from;
http://www.themountaineer.com/archives/2006/12/04/topstories_erdocsoutnewfirmin.html

Hospital Administration's alleged complaints.
A) upgrade the emergency department's electronic medical records
B) right to interview physicians prior to final medical staff approval of hiring
C) being able to temporarily remove emergency doctors off the schedule
D) requiring doctors to provide central line intravenous access for patients
E) providing continuing education for emergency department nurses
F) complying with hospital bylaws by providing timely patient records
G) signing a clause agreeing not to compete with the hospital
H) requiring the emergency department director to provide an annual quality initiative program
I) establishing protocols for the delivery of health care to patients.

Hospital are run exclusively for the benefit of the Key Hospital Administrators. While the top administrators will talk endlessly about importance of quality patient care, They really only care about making their job easier and making more money for themselves.

If you read, the Hospital Administration's alleged complaints you see some disturbing trends that are repeated time after time which is why administrator's would prefer to employ a management company to instead of allowing an Emergency medicine group to work at their hospital. The main thing boils down to the Hospital Administration desire for more power over the ED and their desire to be able to get rid of any physician they do not like with one phone call. With an independent group the Hospital Administration would have go through the credentialing process and have take the time to formulate reasons why they want to kick out a physician and they many not succeed immediately plus they may get sued. With a Management company they can get rid of a physician with one phone call to the Management company. There is the added benefit that many Management Companies come to town once a month and take the key Hospital Administrators out to the best restaurant in town to give them envelopes full of C-notes.

BKN · Jan 7, 2007

A general comment, that may have no applicability to the case presented. Mostly, when a group loses a contract it is because they have made life hard for the administration. Most CEOs have no desire to spend their time micromanaging the ED. Many small groups hold their contracts for many years with no difficulty.

If you want to lose your contract, be rude, unresponsive or arrogant.

Hayduke · Jan 7, 2007

docB,
Thank you for posting this series. I appreciate your posts re:the business of EM.
I have a few questions for you and the veteran posters on the board.

Is this an unusual situation? It makes sense that the administration would cut a group that costs more and apparently makes a mess of the nurse/doc relationship. But, how low would an administration go? If medical staff/admin relationships are not worth preserving, what other recourse does a group have?

How long are typical contracts? It seems like 24 months is a pretty short life span on which to base a move.

Is Phoenix a group that will soak up contracts no matter the cost so that they can penetrate an area? How common is this model?
Are EPs employed by groups like this predominantly independent contractors, benefited employees, or shareholders that benefit from productivity?

Thanks

denied · Jan 7, 2007

BKN said:
A general comment, that may have no applicability to the case presented. Mostly, when a group loses a contract it is because they have made life hard for the administration. Most CEOs have no desire to spend their time micromanaging the ED. Many small groups hold their contracts for many years with no difficulty.

If you want to lose your contract, be rude, unresponsive or arrogant.

I agree that, "If you want to lose your contract, be rude, unresponsive or arrogant." but I think that it is seldom that simple, most groups know that they have to keep the administrators happy to keep the contract. The real issue is can a private group compete with a national management company. How ridiculous a request can the Administration make before you say have to say, No.

1)Will you fire a partner in your group, a very good clinician, because the administrator say that that want him gone but can not offer a valid reason.

2)Will you allow that Administration to force you to use a new computerized record system that replaces dictation and forces you to waste time typing information in a ill-conceived cumbersome system that crashes all the time and forces your group the increase staffing in the ED by 33% or forces you to stay late after your shift for 3 to 4 hours to complete records you previously were able to easily complete while seeing patients.

3)Will you allow the administration to force you to place central lines on ICU patients and take all the calls from nurses during the night, so the intensivists and surgeons do not have to get called in after hours to take care of their patients.

4) Will you give up your nights and weekends to provide house education programs for the hospitals nurses so the hospital administration will not have to fund nurses going to nursing education out side the hospital.

A management company will promise the hospital Administration anything they want and due to their ability to sucker in new graduates and other physicans willing to work for less or to work for the promise of a bonus that will never get paid. Management Companies have almost no additional cost for providing these extra services. The management company is used to going through doctors as quickly as your local minimum wage restaurant so they will fire any doctor the administration does not want instantly without requesting any explanation.

From;
http://www.themountaineer.com/archives/2006/12/20/topstories_emergencydocsmeetwit.html

"It is clear to us the agenda of this administration is to get rid of us," Zaslow said. "The so-called major sticking point is an illusive phenomenon — none of which the hospital board can latch on to and defend in any way. It makes you start thinking, ‘What is this really about?'"

Zaslow said hospital officials have put in writing the issue is not about quality of care or conduct or character, so what's left?, he asked.

Dr. Mark Jaben agreed the issues put forth by the administration keep shifting and don't seem to present clear reasons for a change. "The emergency department is a community's health care safety net," he said. "At its core, this whole issue is a struggle about how this hospital makes its decisions."

docB · Jan 7, 2007

BKN said:
A general comment, that may have no applicability to the case presented. Mostly, when a group loses a contract it is because they have made life hard for the administration. Most CEOs have no desire to spend their time micromanaging the ED. Many small groups hold their contracts for many years with no difficulty.

If you want to lose your contract, be rude, unresponsive or arrogant.

This is very true. Administrators do like to pick up fads and then force them on the ED. When the clinicians tell them it won't work they come back with "Oh, you guys always hate chance." If I get told to read "Who Moved My Cheese?" one more time I'll go ballistic. This is how we've wound up with non emergent screening exams, labs only in panels to facilitate "appropriate ordering," then labs only piece meal to stop over ordering, and so on.

I think it's important for the students and residents to understand that as contract docs we run into situations where we have very little power. A hospital can just not renew your contract and you're gone. They don't have to have any real reason (they have to have a reason to terminate a contract which is spelled out in the contract but when you negotiate a new contract all bets are off). If the hospital wants something bad enough that they are willing to disrupt the ED to replace you then you don't have much choice. It's better to be a strong, clinically astute group so the disruption of bouncing you will be scary for the hospital.

In this North Carolina situation I would guess (I don't know) that the admin has been promised some economically attractive things by the new group and so they threw some poison pills into the contract with the existing group. If you have to accept the hospital hiring and firing your docs you're basically not a group. At that point you might as well just be individuals contracted tot he hospital. Hospitals have plenty of ways to have quality input on docs via the credentials board, QA/QC and equivalent committees and so on.

docB · Jan 7, 2007

Hayduke said:
Is this an unusual situation? It makes sense that the administration would cut a group that costs more and apparently makes a mess of the nurse/doc relationship. But, how low would an administration go? If medical staff/admin relationships are not worth preserving, what other recourse does a group have?

It's not an unusual situation. It usually doesn't play out in the press like this one did but the contract shuffle happens all the time. How low will an admin go? Remember that for them it's just business (Corleone style) and their heads go on the block if they don't make money. If they get a suitor for the contract promising cheaper better faster and maybe some other things under the table like not admitting as many uninsured they'll go for it. I think that the admin had their mind made up and wanted the new group so the sabotaged the contract with the old group. Groups don't have any recourse other than trying to make the hospital a better offer than the new group.

Hayduke said:
How long are typical contracts? It seems like 24 months is a pretty short life span on which to base a move.

2 years is typical. That is why you want to assess how solid the contract is for a group (corporate or independent) before you take a job.

Hayduke said:
Is Phoenix a group that will soak up contracts no matter the cost so that they can penetrate an area? How common is this model?
Are EPs employed by groups like this predominantly independent contractors, benefited employees, or shareholders that benefit from productivity?

Usually ICs. You're right to think about a group loss leading to break into a new market and that does happen. I don't think it's happening here because the town (Clyde, NC) is pretty isolated with one ED and it not much of a market to penetrate.

I work for EmCare so I don't ahve anything against corporate groups in general but they can be predatory. It's just a fact of life that there are predatory groups out there who will want your contract. Welcome to EM.

Hayduke · Jan 7, 2007

docB said:
Welcome to EM.

Yipes!!

Thanks again for the posts, response, and uh......scary as hell education.

Febrifuge · Jan 8, 2007

Yes, this is the sort of education I need, and I suspect my PA program won't be giving me too much insight and help, when it comes to issues like this. At interview day, many of the current 2nd-years (the folks who will be graduating this spring) talked about how the program is so strong and well-respected that it's not unusual at all to get a job offer from a rotation site. We interviewees were duly impressed. But then I got to thinking...

On the one hand, cool. On the other hand, hoo boy, I wonder how well those young 'uns negotiate, and how good their jobs really are?

DocB said:
If the hospital wants something bad enough that they are willing to disrupt the ED to replace you then you don't have much choice. It's better to be a strong, clinically astute group so the disruption of bouncing you will be scary for the hospital.

By this token, I would assume it's better to JOIN a strong group, eh? So... what are signs to look for, as a young new grad evaluates a job offer?

docB · Jan 9, 2007

Febrifuge said:
By this token, I would assume it's better to JOIN a strong group, eh? So... what are signs to look for, as a young new grad evaluates a job offer?

Look for a group that has been there for a long time. Ask how the group is represented on critical hospital committees like med exec, credentials, QA/QC and so on (these have different names at different places but they all do the same things). Ask if the hospital has any input into the hiring and firing process. Ask if the hospital has forced any docs or PAs out.

Some of these questions border on proprietary info and they may not want to share. Some groups will be impressed that you care about such things. Play it by ear at the interview.

Another side note: really restrictive non compete clauses in a contract tend to be a symptom of insecurity about the contract.

sallyjoe · Jan 11, 2007

Febrifuge said:
So... what are signs to look for, as a young new grad evaluates a job offer?

Good post from an Anesthesia thread about how to properly research a job so you know what you kind of mess you are jumping into.

chesterfield said:
Keep a copy of every communication you have with the group. Record or immediately write a summary of all oral conversation with any group members.

Use this opportunity to investigate the practice. Before you go check out the hospital web site for the names of the Anesthesia doctor who work there. Your goal is to find the names of all the doctors who have left the practice in the last few years. Google all of those names along with the names of the corporation. Asking for this information from the group will get you labeled as a malcontent but to take a job with out an investigation the backgrounds of your employers is a recipe for disaster.

When you get there try to get as many months of the call schedule as possible. Old call schedules often have phone number of recently departed members of the group, plus they tell you how fair the call schedule is.

While you are in town go to the county court house and look up the names of all of the members of the group looking for lawsuits.

If your interview goes well and you are seriously considering the group you need to contact the people who have left to get the real information about how he group treats its employees.

How to find old employees of a group;

Look up all the anesthesiologist in that town with the state licence database,
http://www.docboard.org/docfinder.html

Look up all the anesthesiologist in that town with the AMA directory, ASA Directories for the last three or four years.

Look up all the anesthesiologist in that town with UPIN number search, great for towns with more than one hospital since it lists the billing address with the name separating out different practice locations.
http://upin.ecare.com/
or
http://www.upinregistry.com/provider_form.asp

Another good database dr-411 since it gives some info not seen elsewhere,
http://www.dr-411.com/default.asp

With all the names you have found you should be able to find a few former employees to contact about the group since this is your best source of unbiased information.

These databases will help you get current names and addresses of former employees.

Google is often helpful.

Searching for current phone number and addresses
http://www.zabasearch.com/

or your favorite directory search database.

Doc board is good for finding some one who has moved;
http://www.docboard.org/docfinder.html
which may give a current address.

If you have no luck you might want to invest a few buck and ask your local detective to search for people you cant locate. They also can search for lawsuits more broadly than the court house.

Now call your names and politely ask them to tell you about there experience at your potential employer.

While this is just the basics, your hospital credential application probably will be ten to twenty pages of invasive questions, many of which will be verified. Why shouldnt you know as much about your potential employer?

If you do not find any skeletons in the closet or areas of concern you need to find a competent lawyer and some trusted friends to look at your contract. Finding a lawyer who knows anything about anesthesia contacts is very difficult many attorneys will claim to be able to review a contact. So just because your buddy and fellow resident used that attorney does not say much about his competence in reviewing anesthesia contacts and providing relevant feedback.

Lastly don't ever buy a house until you have been there at least a year or made partner.
But dont say that to the realtor they force you to take a tour of the town with, you can be sure that everything you say to her will funnel back the anesthesia group.

Cut-throat Contract Wars in EM

docB

Chronically painful

WestcoastMedicine

Senior Member

ForbiddenComma

Tanned for Bowling

denied

Full Member

BKN

Senior Member

Hayduke

Member

denied

Full Member

docB

Chronically painful

docB

Chronically painful

Hayduke

Member

Febrifuge

Grizzled Old Newcomer

docB

Chronically painful

sallyjoe

Full Member

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