corporate practice of EM...whats so bad?

[WakeDoc]

So...I just got back from one of those great "ACME-EM" dinners where some corporation that has 5000 hospitals across the nation tells you how great they are. Well, I don't know about the company, but the food was fantastic. Anyway, could somebody please enlighten me as to what the real horrible issues are w/ corporate medicine? I understand the hiring of non-EM trained physicians, but many of the companies state that they have stopped this practice. I have read "The Rape of Emergency Medicine," which portrays a horribly bleak picture of corporate medicine, but this book is from the 80's, and frankly I don't see anything along those lines still happening. Clearly, there is a reason that so many leaders in our field have spoken out against it...but I have yet to really understand the fundamental issues at hand.

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[bookite]

First, I don't know a lot about the issue but from what I see it is shareholders making money off of your work. Shareholders like to make money and when things go as planned everyone is happy. If money is not being made this is where things might go wrong.
There are pros and cons as with everything. I think the biggest issue I see is people making money off your hard work.
The a few of the pros are they take care of everything (billing, malpractice, hiring and firing, etc) and have buying power (healthcare, benefits etc)

Maybe some others could add to the issue.

 

[docB]

Let me disclose that I work for EmCare and I’m an ACEP Fellow and an ACEP state officer so I’m not totally unbiased here. That said I have a lot of respect for AAEM and I think that they are fighting the good fight on many issues and their efforts have led to reforms within the corporate groups.

I’ll try to take both sides of some of these issues. I’m sure some of the AAEM guys will add to whatever I say.

As I see it the main issues that the anti-corporate EM folks have are about money going to non-physicians (e.g. administrators, stockholders), restrictive covenants and conflicts of interest. Let me try to explain.

The anti-corporate crowd feels that it is wrong for anyone other than the physician to make money from the physician’s work. It’s unfair for a patient to pay extra just because they are getting seen by a doc who works for a corp and if the patient isn’t paying extra it’s unfair for the doc to make less because they work for a corp. You could say that even if it’s unfair to the doc that’s the doc’s fault for signing on. Their rebuttal is that corps are so widely dominant that many docs don’t have a choice.

The counter point to that is that every practice will have overhead. If you and your group decide that your needs are better served by being managed by a corp than by doing it yourselves then that’s just a business decision. Because of the “bulk buying” ability of larger entities like a staffing corp some groups come out ahead by going with corp management despite because corp overhead costs + profit = less than their local overhead costs.

Restrictive covenants are contracts that restrict docs from doing things that a corp wouldn’t want them to do. The classic example was the “non-compete clause.” This is a highly dubious clause that used to be widely used by corp groups. It usually said something along the lines of “If you quit our group you can not work within a 50 mile radius of our contract hospital for 2 years.” That clause would usually force a doc to leave town if he wanted to change jobs. The rational put forward for this on the part of the corps was that a doc could take the things he learned about how a group did things and take it to a nearby hospital, replicate it and compete with the original hospital. The more important reason was that this gave the corp huge leverage over the docs. “Do things the way we say or leave town.” The anti-corp guys make a good point that restricting a doc from working just because he’s changed jobs is wrong and it hurts patients by allowing corps to have huge power over not just the availability of physicians in a given area but their practice patterns as well.

Restrictive covenants have really become less of an issue. I don’t know anyone who is working under an old style clause. The usual clause now says that you can work wherever you want. You just can’t come back to a hospital you quit and try to take the EM contract away from the corp group for a given amount of time.

The conflict of interest argument has to do with the idea that a corp is in business to make money first and treat patients second. That is true but it does not mean that both can not be accomplished well. While private groups don’t have stockholders they do have profit motive. The idea that there can be no profit motive behind the provision of healthcare quickly leads to a debate about socialized healthcare and I will not bring up that stinking, beaten, horse corpse here.

 

[GeneralVeers]

I also work part-time for EmCare (TX and CA). Despite the bad things I've heard about them, they've been nothing but helpful with travel provisions, even paying for flights, hotels, cars, etc when they need someone to cover last minute. Their pay is very fair, and their payroll and credentialing departments are top notch, and have always been available to help when I call.

 

[Aloha Kid]

Our residency invited Dr Robert McNamara (former president for AAEM) over for Grand Rounds last year. He gave a fiery speech about the subject entitled "THE RAPE OF EMERGENCY MEDICINE." By the end of it every single resident seemed agitated and disgusted about the "evils of corporate medicine." One of our attendings who is a big advocate for AAEM offered free memberships to the first 5 residents who came up to talk with him.

We settled down after we realized our attendings were all part of a corporate group. The point is, we as residents are so ignorant regarding business issues. For good or for worse, someone will always try to take a cut out of your paycheck. Just know the issues and make sure you are comfortable with it when looking for a job.

 

[docB]

For good or for worse, someone will always try to take a cut out of your paycheck. Just know the issues and make sure you are comfortable with it when looking for a job.

That's a really good point. The corporations are not evil but they are businesses. If you really want to have absolute autonomy as to your administrative functions you won't be happy in a corporate group. If you care less about that a corp group might be fine.

 

[EctopicFetus]

I think the amount of money might be an issue too. I know in SoAz and Phoenix working for a purely democratic private group you can make seriously 2x as much money per hour once you are a partner. Now to be fair 1) I moonlight for EmCare and 2) I will prob try to go private cause I dont mind administrative work and at least where I live it is much much more lucrative.

Of course until you become a partner, those partners are eating up your money and more importantly, sometimes it can take up to 5 years around here to be a "full partner".

Bottom line I think is geography is key, then you have to see 1) who is hiring 2) what kind of job you want (punch in punch out vs lots of extra admin work).

As mentioned EmCare has really really been good to me. Now I am just a moonlighter but they really seem to have their act together and are quite prompt in responding.

 

[atelectasis]

Do any corporate EP's get stock options? I mean, if you're an EMCare employed doc, can you get stock options on EMS stock (which is currently hovering around the 52 week high at ~$34)?

 

[docB]

Do any corporate EP's get stock options? I mean, if you're an EMCare employed doc, can you get stock options on EMS stock (which is currently hovering around the 52 week high at ~$34)?

We got an offer for options a few years ago. It's not a regular thing but it does happen.

 

[GeneralVeers]

We got an offer for options a few years ago. It's not a regular thing but it does happen.

My group (Not EmCare) gives "shares" for each month worked with the group. Exactly what the shares do, I haven't determined yet.

 

[aequanimitas]

So...I just got back from one of those great "ACME-EM" dinners where some corporation that has 5000 hospitals across the nation tells you how great they are. Well, I don't know about the company, but the food was fantastic. Anyway, could somebody please enlighten me as to what the real horrible issues are w/ corporate medicine? I understand the hiring of non-EM trained physicians, but many of the companies state that they have stopped this practice. I have read "The Rape of Emergency Medicine," which portrays a horribly bleak picture of corporate medicine, but this book is from the 80's, and frankly I don't see anything along those lines still happening. Clearly, there is a reason that so many leaders in our field have spoken out against it...but I have yet to really understand the fundamental issues at hand.

While the video is a general comparison of AAEM versus ACEP, this video--which is posted on the AAEM website--might help to shed some light as well as the great posts here. The video is a moderated discussion/debate between Robert McNamara of AAEM and Art Kellerman of ACEP at Temple Grand Rounds. It most definitely touch upon the corporate emergency medicine issue. Enjoy

http://www.aaem.org/aboutaaem.php

Click on the AAEM/ACEP Video link on the left of the screen