I've noticed some previous discussion of this issue before. The following letters are taken from The Journal of Emergency Medicine, Volume 25, #3, October 2003. Pages 337-338.
Whether you agree with the statements or not, if you are going to be an ED doc, it's very much in your interest to understand these issues. (I scanned the articles into text, so there may be an occasional typo.)
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AAEM Opposes TeamHealth Residency
The following letters were sent to the Residency Review Committee for Emergency Medicine (RRC-EM) by AAEM's Executive Committee. The letters expresses concern over the TeamHealth sponsorship of a Florida Emergency Medicine Residency.
April 21, 2003
Dear Dr. Sanders and members of the RRC-EM,
On behalf of the American Academy of Emergency Medicine, I am writing to you with great concern regarding the Tampa General Hospital Emergency Residency Program and its sponsorship by TeamHealth as detailed in the April 2003 issue of Emergency Physician's Monthly. As you are aware, the operating methods of corporate contract management groups such as TeamHealth are a concern in our specialty. The representatives from TeamHealth quoted in the mentioned article go to great lengths to point out that they will not profit from this venture. Even if there was no direct profit from this, the economic benefits to TeamHealth in terms of the marketplace are enormous. The legitimacy obtained by the blessing of this arrangement by the RRC-EM will aid this company in securing other ED contracts and enhance their status among physicians seeking EM opportunities. We at the American Academy of Emergency Medicine have serious concerns about this arrangement. It is imperative that any corporation allowed to do business with the RRC-EM remain beyond reproach in order to preserve the integrity of the RRCEM and the ACGME in their important roles of overseers of resident education. Dr. Sanders, you especially as an appointee to the RRC-EM from the AMA need to be aware of potential conflict with AMA policies posed by this arrangement. Specifically, our concerns are as follows:
1) Due Process for the faculty
Due process is essential to the academic mission. Corporate EM by and large denies physicians the right to this. The AMA and its Council on Ethical and Judicial Affairs (Opinion 9.05) hold this as a core right of physicians. Has the RRC-EM been given clear proof that the faculty at Tampa General will have the right to due process consistent with AMA policy H265.998? Will the faculty be able to freely speak out about corporate and hospital policies that affect the academic mission?
2) Fee splitting and open books
Corporate EM is based in profiting from the labors of physicians. Typically, the emergency physicians are not shown what is billed and remitted under their provider number. This is in direct conflict with AMA policy H-190.971. Additionally, if the physicians are giving up more than fair market value for the services TeamHealth provides they may be involved in prohibited fee splitting activities (1). Has the RRC-EM been given proof that the faculty physicians at Tampa General will be given open access to the billings and remittances made under their provider number? Has the RRC-EM performed or requested that the ACGME or the AMA investigate whether the corporate operating methods of TeamHealth constitute fee splitting, a prohibited activity at the state and federal level, and a direct violation of the AMA Council and Ethical Affairs opinion 6.02?
3) Restrictive covenants
Corporate EM typically includes a restrictive covenant in the physician contract. AMA policy (H-140.942) discourages the use of restrictive covenants in medicine. If TeamHea1th loses the contract for services with Tampa General has the RRC-EM been given proof that all of the faculty physicians will be able to stay at the site without penalty to them or the hospital?
4) The corporate practice of medicine
Team Health is a corporation; they own the emergency services contract for Tampa General and approximately 300 other facilities. TeamHea1th employs physicians and derives corporate profit from the physician fees. Has the RRC-EM performed or asked the ACGME or the AMA to perform due diligence to look into whether TeamHea1th is engaged in the prohibited corporate practice of medicine either in Florida or elsewhere?
Certainly, it is pertinent to the RRC-EM approval of a corporation's sponsorship of a residency program to ensure that the corporation does not engage in matters such as fee splitting or the prohibited corporate practice of medicine either in the context of the residency or in the corporation's other activities. It would seem imperative to have conducted such an investigation. If such has not occurred we request that you solicit the AMA through the ACGME to do so. Additionally, one would hope that any corporation receiving such an endorsement by the RRC-EM would be held to the standards of AMA policies, a member organization of the ACGME. The American Academy of Emergency Medicine has definitive evidence in the form of physician contracts that TeamHealth does not follow AMA policy in the matters of due process and restrictive covenants.
The American Academy of Emergency Medicine awaits your response on this important matter.
Sincerely,
Joseph P. Wood, MD, JD, FAAEM
President, AAEM
Robert M. McNamara, MD, FAAEM
Immediate Past President, AAEM
Antoine Kazzi, MD. FAAEM
Vice President, AAEM
Tom Scaletta, MD, FAAEM
Secretary-Treasurer, AAEM
Reference:
(1) Kalifon D, Sullivan DJ. before you sign: Contract basics for the emergency physician. The American College of Emergency Physicians, Dallas, TX 1996, p. 22
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July 8, 2003
Larry D. Sulton, PhD
Executive Director
Residency Review Committee -EM (RRC-EM)
Re: Appointment Process for the RRC-EM
As you are aware we recently communicated with the RRC-EM regarding the issues related to the Tampa General/TeamHea1th EM residency (4/21/03). In that letter we expressed our concerns regarding corporate influence on the educational program. The fact that we had to write the RRC-EM regarding this matter in the first place suggests to us that there should be a review of the process for selecting the membership of this body. The ACGME web site (www.acgme.org/about/roleAcgme.asp) states that "appointing organizations to all RRCs include the American Medical Association (AMA) and the member boards of the American Board of Medical specialties (ABMS). In many specialties, the academic specialty organization also appoints a portion of the RRC members."
We ask why this is not followed for the specialty of Emergency Medicine? RRC-EM appointments are made by the American College of Emergency Physicians (ACEP), a general specialty society, and not by the Society for Academic Emergency Medicine (SAEM), the recognized academic specialty organization."
This is highly pertinent in follow up to the discussion of corporate issues regarding TeamHealth involved in an EM residency. We note that the immediate past chairperson. Robert Strauss, MD, FACEP who was appointed through ACEP is not an academician but the Chief Medical Officer for PhyAmerica, a national ED staffing corporation of the same nature as TeamHealth (www.phyamerica.com/PPS/physician_leadership_nf.htm). If one is to isolate the educational process from corporate influence it seems one should have academicians and not corporate leaders as the members of the RRC. We would appreciate an explanation on why the process for appointment to the RRC-EM does not follow the stated ACGME guidelines. We specifically request that the appointment process be revised to substitute SAEM for the ACEP.
Sincerely,
Joseph P. Wood, MD, JD, FAAEM
President, AAEM
Antoine Kazzi, MD, FAAEM
Vice President, AAEM
Robert M. McNamara, MD, FAAEM
Immediate Past-President, AAEM
Tom Scaletta, MD, FAAEM
Secretary-Treasurer, AAEM
Whether you agree with the statements or not, if you are going to be an ED doc, it's very much in your interest to understand these issues. (I scanned the articles into text, so there may be an occasional typo.)
----------------------------------------------------------------------------------
AAEM Opposes TeamHealth Residency
The following letters were sent to the Residency Review Committee for Emergency Medicine (RRC-EM) by AAEM's Executive Committee. The letters expresses concern over the TeamHealth sponsorship of a Florida Emergency Medicine Residency.
April 21, 2003
Dear Dr. Sanders and members of the RRC-EM,
On behalf of the American Academy of Emergency Medicine, I am writing to you with great concern regarding the Tampa General Hospital Emergency Residency Program and its sponsorship by TeamHealth as detailed in the April 2003 issue of Emergency Physician's Monthly. As you are aware, the operating methods of corporate contract management groups such as TeamHealth are a concern in our specialty. The representatives from TeamHealth quoted in the mentioned article go to great lengths to point out that they will not profit from this venture. Even if there was no direct profit from this, the economic benefits to TeamHealth in terms of the marketplace are enormous. The legitimacy obtained by the blessing of this arrangement by the RRC-EM will aid this company in securing other ED contracts and enhance their status among physicians seeking EM opportunities. We at the American Academy of Emergency Medicine have serious concerns about this arrangement. It is imperative that any corporation allowed to do business with the RRC-EM remain beyond reproach in order to preserve the integrity of the RRCEM and the ACGME in their important roles of overseers of resident education. Dr. Sanders, you especially as an appointee to the RRC-EM from the AMA need to be aware of potential conflict with AMA policies posed by this arrangement. Specifically, our concerns are as follows:
1) Due Process for the faculty
Due process is essential to the academic mission. Corporate EM by and large denies physicians the right to this. The AMA and its Council on Ethical and Judicial Affairs (Opinion 9.05) hold this as a core right of physicians. Has the RRC-EM been given clear proof that the faculty at Tampa General will have the right to due process consistent with AMA policy H265.998? Will the faculty be able to freely speak out about corporate and hospital policies that affect the academic mission?
2) Fee splitting and open books
Corporate EM is based in profiting from the labors of physicians. Typically, the emergency physicians are not shown what is billed and remitted under their provider number. This is in direct conflict with AMA policy H-190.971. Additionally, if the physicians are giving up more than fair market value for the services TeamHealth provides they may be involved in prohibited fee splitting activities (1). Has the RRC-EM been given proof that the faculty physicians at Tampa General will be given open access to the billings and remittances made under their provider number? Has the RRC-EM performed or requested that the ACGME or the AMA investigate whether the corporate operating methods of TeamHealth constitute fee splitting, a prohibited activity at the state and federal level, and a direct violation of the AMA Council and Ethical Affairs opinion 6.02?
3) Restrictive covenants
Corporate EM typically includes a restrictive covenant in the physician contract. AMA policy (H-140.942) discourages the use of restrictive covenants in medicine. If TeamHea1th loses the contract for services with Tampa General has the RRC-EM been given proof that all of the faculty physicians will be able to stay at the site without penalty to them or the hospital?
4) The corporate practice of medicine
Team Health is a corporation; they own the emergency services contract for Tampa General and approximately 300 other facilities. TeamHea1th employs physicians and derives corporate profit from the physician fees. Has the RRC-EM performed or asked the ACGME or the AMA to perform due diligence to look into whether TeamHea1th is engaged in the prohibited corporate practice of medicine either in Florida or elsewhere?
Certainly, it is pertinent to the RRC-EM approval of a corporation's sponsorship of a residency program to ensure that the corporation does not engage in matters such as fee splitting or the prohibited corporate practice of medicine either in the context of the residency or in the corporation's other activities. It would seem imperative to have conducted such an investigation. If such has not occurred we request that you solicit the AMA through the ACGME to do so. Additionally, one would hope that any corporation receiving such an endorsement by the RRC-EM would be held to the standards of AMA policies, a member organization of the ACGME. The American Academy of Emergency Medicine has definitive evidence in the form of physician contracts that TeamHealth does not follow AMA policy in the matters of due process and restrictive covenants.
The American Academy of Emergency Medicine awaits your response on this important matter.
Sincerely,
Joseph P. Wood, MD, JD, FAAEM
President, AAEM
Robert M. McNamara, MD, FAAEM
Immediate Past President, AAEM
Antoine Kazzi, MD. FAAEM
Vice President, AAEM
Tom Scaletta, MD, FAAEM
Secretary-Treasurer, AAEM
Reference:
(1) Kalifon D, Sullivan DJ. before you sign: Contract basics for the emergency physician. The American College of Emergency Physicians, Dallas, TX 1996, p. 22
-----------------------------------------------------------------------------------
July 8, 2003
Larry D. Sulton, PhD
Executive Director
Residency Review Committee -EM (RRC-EM)
Re: Appointment Process for the RRC-EM
As you are aware we recently communicated with the RRC-EM regarding the issues related to the Tampa General/TeamHea1th EM residency (4/21/03). In that letter we expressed our concerns regarding corporate influence on the educational program. The fact that we had to write the RRC-EM regarding this matter in the first place suggests to us that there should be a review of the process for selecting the membership of this body. The ACGME web site (www.acgme.org/about/roleAcgme.asp) states that "appointing organizations to all RRCs include the American Medical Association (AMA) and the member boards of the American Board of Medical specialties (ABMS). In many specialties, the academic specialty organization also appoints a portion of the RRC members."
We ask why this is not followed for the specialty of Emergency Medicine? RRC-EM appointments are made by the American College of Emergency Physicians (ACEP), a general specialty society, and not by the Society for Academic Emergency Medicine (SAEM), the recognized academic specialty organization."
This is highly pertinent in follow up to the discussion of corporate issues regarding TeamHealth involved in an EM residency. We note that the immediate past chairperson. Robert Strauss, MD, FACEP who was appointed through ACEP is not an academician but the Chief Medical Officer for PhyAmerica, a national ED staffing corporation of the same nature as TeamHealth (www.phyamerica.com/PPS/physician_leadership_nf.htm). If one is to isolate the educational process from corporate influence it seems one should have academicians and not corporate leaders as the members of the RRC. We would appreciate an explanation on why the process for appointment to the RRC-EM does not follow the stated ACGME guidelines. We specifically request that the appointment process be revised to substitute SAEM for the ACEP.
Sincerely,
Joseph P. Wood, MD, JD, FAAEM
President, AAEM
Antoine Kazzi, MD, FAAEM
Vice President, AAEM
Robert M. McNamara, MD, FAAEM
Immediate Past-President, AAEM
Tom Scaletta, MD, FAAEM
Secretary-Treasurer, AAEM
