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Death of the Contract Managment Group?

GeneralVeers

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    Large Contract Management Groups (CMG) have exploded, and now dominate most contracts. Teamhealth, EmCare, CEP, EMP control most of the large hospital contracts in the country.

    I think their days are numbered, and with good reason.

    Accountable Care Organizations (ACOs) are coming. ACOs will be made up of insurers, hospital systems and physician groups. These are in response to the new bundled payment structure coming from CMS. Under this new payment plan fee-for-service will go away, and payment will be made for an "episode of care" and include "quality measures". That means the surgeon, hospital, internist, and ER doctor will have one pool of money from which they all get paid. The reason for all of this is that it's a smoke-and-mirrors method of cutting medical costs without angering the AARP through direct cuts to Medicare.

    The reason that CMGs are doomed is that the ER doctor has no place in this new ACO structure. ACOs are not going to pay any more money for a re-admission within 30 days for the same problem. So imagine a CHFer gets sent home too soon and bounces back to the ER. Will we get paid for seeing them? Under an ACO model, we won't as it would technically still be the same "episode of care" and that money has already been spent. CMGs will be dinosaurs, since fee-for-service billing will be a thing of the past, and the hospital, will likely be determining how much is paid out to us. This means that we will probably be transitioned to a Kaiser model, whereby a hospital system directly employs us and pays us hourly. Additionally because of the "quality measures", hospitals will want to keep us on a tight leash so they can minimize the loss of payments for missing quality metrics.

    We can already see this happening with large groups like CEP who have aligned themselves with large hospital systems like Dignity Health in anticipation of the ACO formation.

    Thoughts?
     

    EctopicFetus

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      I dont work for a CMG. I think though that CMGs will flourish. They have quality systems in place that hospitals dont. I think the role of the CMG will change as it will instead be like a 3rd party HR system. I think this is much of what they do now but they will lose their power. Most places have a hard time attracting ED docs. the CMGs help with this. Hospitals who cant staff their EDs dont have the resources to hire docs as often as needed. The CMGs have recruiting down to a science.
       

      TrumpetDoc

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        Good points on both. I too, work for a CMG, and the best way to picture them right now is Like a telemarketing co on the 90s (I had the "honor" of working for one in college). They are scampering, going nuts trying to find ways to "stay relevant" to the hospital systems. They are diversifying their practice at a light speed pace. Almost literally overnight we are now not an EM group, we are a "medical front end" firm...trying to take charge of all aspects of prehospital and early acute care...including discharge aftercare!!!...with more pay??? Hell no!

        While this is all good from the corporate standpoint, where does this leave the working ED docs?..suppose it won't matter much as in the very near future the departments will be fully staffed with PAs/NPs with maybe one EP to sign off and/or get in on critical cases. Hospitals will mandate this as a part of "keeping your contract"...just watch. Can our CMGs (or any group) fight for us? Nope, lose the contract.

        True though too, is the virtual HR concept, especially in less desirable places. But in cities where there is no shortage of people wanting to work, I think Veers' view could hold very true.

        Sorry for typos.
        Busy time and iPhone... Bad mix.
         
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        Arcan57

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          Good points on both. I too, work for a CMG, and the best way to picture them right now is Like a telemarketing co on the 90s (I had the "honor" of working for one in college). They are scampering, going nuts trying to find ways to "stay relevant" to the hospital systems. They are diversifying their practice at a light speed pace. Almost literally overnight we are now not an EM group, we are a "medical front end" firm...trying to take charge of all aspects of prehospital and early acute care...including discharge aftercare!!!...with more pay??? Hell no!

          While this is all good from the corporate standpoint, where does this leave the working ED docs?..suppose it won't matter much as in the very near future the departments will be fully staffed with PAs/NPs with maybe one EP to sign off and/or get in on critical cases. Hospitals will mandate this as a part of "keeping your contract"...just watch. Can our CMGs (or any group) fight for us? Nope, lose the contract.

          True though too, is the virtual HR concept, especially in less desirable places. But in cities where there is no shortage of people wanting to work, I think Veers' view could hold very true.

          Sorry for typos.
          Busy time and iPhone... Bad mix.

          I don't think the hospital can keep its metrics with the ED equivalent of the current anaesthesia model. Pts love our APCs (the new term for midlevel), but even with their overall lower acuity (predominantly staffing fast track and an 8 bed intake area) they aren't seeing as many patients as the doc. We exist as a specialty because we do the job better then anyone else (including other docs), I don't think care has standardized to the point that we can be replaced without catastrophic consequences. Although I bet anaesthesia probably felt the same back in the 90s.
           

          TrumpetDoc

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            Very good point, and I think we would all agree.

            We had a presentation by a hospital system CEO at a regional meeting.
            He was very blunt in making it known that their EPs will have a choice...get cut on reimbursements , or downstage docs and up mid levels. This is from a Midwest system that has been doing an ACO equivalent model for th las two years.
            Very scary.
            Interestingly, he mentioned the ONLY reason they have not "yet" employed the ED docs, was the benefits and med mal.

            The air was completely sucked out of the room!! Bad stuff :(
             

            TrumpetDoc

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              Hopefully, Arcan, his hospitals will realize your points and see their ED grind to a halt.

              Unfortunately as was pointed out in the budget thread, people cannot comprehend what's not right in their face (Can't comprehend CEOs abilities, sacrifices, educations etc.) when it comes to mid levels and us.
              To nurses and hospital admin, we (EPs) are expendable not only as a contract holder, but as a necessity in the department in general. Ever eves drop on RNs talking up MLPs to equal to us??? I have, many times.

              I wonder if surgeons will be the only relevant species left over when the dust settles. There, you have a difference that is readily appearent...cutting someone open needs a "surgeon" in the minds of people/admin.
              I think we are kidding ourselves if we think "quality" and expertise of the physician means anything to the hospitals anymore.
              They will have MLPs and then a "certification" for critical care MLPs for the sick cases... All will be more "cost effective" especially as we continue to fight for our rightful $$
               

              RustedFox

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                Very good point, and I think we would all agree.

                We had a presentation by a hospital system CEO at a regional meeting.
                He was very blunt in making it known that their EPs will have a choice...get cut on reimbursements , or downstage docs and up mid levels. This is from a Midwest system that has been doing an ACO equivalent model for th las two years.
                Very scary.
                Interestingly, he mentioned the ONLY reason they have not "yet" employed the ED docs, was the benefits and med mal.

                The air was completely sucked out of the room!! Bad stuff :(


                Explain what you mean by this.
                 

                RustedFox

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                  CMGs have been negative as a whole for the profession (and I work for one). Because of them we've become replaceable cogs in the giant machine. Because of them we are stuck with things like Press-Ganey that make our jobs miserable.


                  Yeeeep.

                  I work for one, too. All they care about is their "door-to-greet", "door to doc", and "door to narc" times.

                  Here's a rich one for you; my medical director (who is a totally cool guy, for the record), told me that my "Duplicate MSE times" were too LOW the other day. That is; When you click on the patient tracker to "sign up" for the patient, and then click on another patient and do the same within 2-3 minutes... you get "dinged", as in: "you really couldn't have seen them both at once". Nevermind that those encounters are "two-fers" and "three-fers" of mothers bringing in batches of children for "the sniffles" (its the season).

                  So... numbers need to be low, but not too low. and dear god, if the average time gets above 30 mins door-to-provider... then the alarm bells ring, backup is called (they may or may not show up), and you have to explain why it is that you're not performing up to par.
                   

                  EctopicFetus

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                    As someone who doesnt work for a CMG you guys make it sound way scary. I did moonlight with Emcare at 2 facilities.


                    IMO if CMGs continue to expand our profession will become even more of a commodity. I dream of the day where they truly do not allow the corporate pracitice of medicine and they allow you guys to have fai democratic groups of which you are the owners.
                     

                    GeneralVeers

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                      As someone who doesnt work for a CMG you guys make it sound way scary. I did moonlight with Emcare at 2 facilities.


                      IMO if CMGs continue to expand our profession will become even more of a commodity. I dream of the day where they truly do not allow the corporate pracitice of medicine and they allow you guys to have fai democratic groups of which you are the owners.

                      We have to see patients within 30 minutes as well. If we start to go over that time we have to take a screenshot of our patient tracker, put it in a special book with the time, and document why it took more than 30 minutes to see patients.

                      Needless to say this takes a lot of extra time during the day, time that could be devoted to actually caring for patients and improving productivity.
                       

                      RustedFox

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                        Fox. Not sure which part to expand on...


                        Veers..."the book" is lame. I might as well just make a habit of taking a shot and placing the screenshot at the start of every shift!

                        This is pretty much my every shift as of lately. I have been "called in early" every day for the past 6-7 shifts, and asked to "stay late to help out".

                        Sure, I'm getting paid for those hours.. but, it doesn't make me happy. Its not the job that I thought that I signed up for.
                         
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                        RustedFox

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                          We have to see patients within 30 minutes as well. If we start to go over that time we have to take a screenshot of our patient tracker, put it in a special book with the time, and document why it took more than 30 minutes to see patients.

                          Needless to say this takes a lot of extra time during the day, time that could be devoted to actually caring for patients and improving productivity.


                          Yep. Its not enough that a nurse has to interrupt me five times every five minutes to "do something more for this patient' pain" or tell me what he/she "thinks is the best management plan for the patient"... I'm also interrupted by having to keep an eye on the clock and saying - "Well, how will I explain this one to Big Brother?"

                          If everyone just sat down, shut up, and let me do my job.... then we might actually see better door-to-doc times.
                           

                          la gringa

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                            thankfully we aren't hammered on door to doc like we were at my first job out of residency... though i think those ED's flowed better.

                            we have this PIT system and i really am not a fan. what good is it for the PIT doc to "see" a patient with abdominal pain and just order a urine and upt? yeah, that really expedites my workup, treatment of pain, etc.

                            not to mention the endless "room 4 doesn't have a riiiide". i understand if it's a chronic misuser of the ED, but if it's a guy w/ angioedema and he doesn't get benadryl, HE ISN'T GETTING TREATED PROPERLY FOR HIS PROBLEM! we are rated for "control of pain" yet nurses constantly try to circumvent this.

                            question: do ya'll allow pts to go home in a cab after getting iv narcs, ativan, phenergan, benadryl if they pass the equivalent of a clinical sobriety test? in residency we could do that, and at my first gig (2 hospitals), but i can't where i am now.
                             

                            RustedFox

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                              question: do ya'll allow pts to go home in a cab after getting iv narcs, ativan, phenergan, benadryl if they pass the equivalent of a clinical sobriety test? in residency we could do that, and at my first gig (2 hospitals), but i can't where i am now.

                              In a cab ? No.

                              With a family member ? Yes.
                               

                              CommunityED

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                                question: do ya'll allow pts to go home in a cab after getting iv narcs, ativan, phenergan, benadryl if they pass the equivalent of a clinical sobriety test? in residency we could do that, and at my first gig (2 hospitals), but i can't where i am now.[/QUOTE]

                                Agree with Fox. Cab no way. Family member sure, why not. Its the same as being d/c'd post op
                                 

                                RustedFox

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                                  If they're clinically sober after the peak effect time? Essentially you're worried about them wandering into traffic or falling and breaking something getting to their house. Clinically sober people generally don't do that.

                                  Disclaimer: *This is a no-"attitude" post.* In no way, shape, or form is this intended to be disrespectful... but rather, self-deprecating and humorous.

                                  Clinically sober people, especially senior citizens, do those things ALL the time. :) From the 18 year-old who is wearing his iPod earbuds while crossing the street, to the 50 year-old female who "just missed the last step", and went headfirst down to the concrete garage floor.

                                  If you're hammered enough to show up in the ED, you already effed up as it is. (See image). I don't trust you.

                                  I "fall" several times a week. I hustle up the steps, and my toes just don't grab the next one. I walk "along" the parking barrier, or try to hop up over a... whatever... and I "just miss" those, too. I don't bite it and take a total digger because 1) I'm sober, and 2) I'm young, and have good reaction time/equillirbium. When I'm sixty, I'm going to take some stumbles. I guarantee it.



                                  24260393.jpg
                                   

                                  Arcan57

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                                    Then what do you use as a time? Being in the company of another person doesn't really protect you from falling (roughly 50% of the falls "in house" occur with family in the room). Do you use a 4 hr cut-off, a 6 hr cut-off? Wait until a certain multiple of the half life has passed? Do you restrain them if they try and leave before then (arguably they can't give informed refusal because of the narcs)? If you have a hospital policy that essentially establishes standard of care then you obviously have to follow that. In the absence of imposition from above, I don't see a fixed wait time meeting the demands of internal consistency. I don't feel super strongly about this so I am open to being persuaded. And to clarify, I'm advocating that if a patient is clinically sober and the peak time of the drug effect has passed they can go in a cab.
                                     

                                    RustedFox

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                                      Then what do you use as a time? Being in the company of another person doesn't really protect you from falling (roughly 50% of the falls "in house" occur with family in the room). Do you use a 4 hr cut-off, a 6 hr cut-off? Wait until a certain multiple of the half life has passed? Do you restrain them if they try and leave before then (arguably they can't give informed refusal because of the narcs)? If you have a hospital policy that essentially establishes standard of care then you obviously have to follow that. In the absence of imposition from above, I don't see a fixed wait time meeting the demands of internal consistency. I don't feel super strongly about this so I am open to being persuaded. And to clarify, I'm advocating that if a patient is clinically sober and the peak time of the drug effect has passed they can go in a cab.


                                      This is a GOOD question.

                                      1.) Before I explain how "my process" (and its unscientific, I will admit) works... I want to re-iterate that my above post is NOT intended to be an affront to you in any way. You are one of the pillars of the forum, and you should be afforded a modicum of respect. In case anyone else reading this thread is confused: The joke was on me. I fall. A lot. And I'm sober when I do.

                                      Now, regarding my "process for sending home the drunk guy". I've actually been working on a "checklist" of items to document to make it "medicolegally safe" to send home the drunk guy. At present, here's my thought process (and this is currently under revision):

                                      1) Document current (not initial) BAL.
                                      2) Have sober, responsible caretaker (family member, friend) there to drive the patient home.
                                      3) Assess and document the drunk fellas' decision making capacity. This usually entails them being able to prove to me that they are AAOx4, can pass a clinical sobriety test, can walk unassisted, have no dysmetria/cerebellar signs, and can demonstrate "higher-order" thought processes (serial 7's, interpreting proverbs, displaying a sense of humor)
                                      4) Document the patient's and their caretaker's understanding of the conditions of their discharge, and their awareness of the "need to return for these (x..y...z..) and any/all other concerns".
                                      5) Document their WISHES to be discharged, and their refusal of further conservative care measures (admission, continued hydration/monitoring were all offered, but patient made clear their refusal of any and all additional measures at the time of discussion and discharge).

                                      This might seem all very cumbersome and wordy, but yeah, I do it. Every time.

                                      I've gotten it down pretty smoothly.

                                      Here's why I go to all the trouble:

                                      We work in a field of medicine where its already been proven that you can do EVERYTHING correctly... and still end up on the wrong end of a multimillion dollar suit... losing your home, your shirt, your car, your everything.

                                      Until that changes... I work like a doctor. I chart like a lawyer. I spent 11+ years busting my ass and going into unthinkable debt in order to do the job that I do.

                                      I'm not just going to "hand it all over" to some jackass that's never worked a day in their life, and has no intentions of ever working a day in their life.

                                      My charts are thick, and full of language. But they serve a very, very important purpose:

                                      "It is better to win the war before the battle is ever begun."

                                      - Sun Tzu "The Art of War".
                                       
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                                      RustedFox

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                                        we have this PIT system and i really am not a fan. what good is it for the PIT doc to "see" a patient with abdominal pain and just order a urine and upt? yeah, that really expedites my workup, treatment of pain, etc.


                                        We're trying something similar at my shop, and its failing miserably. Its some scheme designed to "punch the clock" at the earliest possible moment.. and it results in multiple transfers of care, lots of information lost in-between each step, and longer stays in the ED on the whole.

                                        Metrics are like bikinis.... they're fun to look at, but they never show you what you're REALLY trying hard to see.
                                         

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                                          Why do you do this?


                                          I gotta admit: I was not clear in my initial post. Thanks, Tkim. You pointed out a glaring inconsistency (in all sincerity).

                                          I document the *current* BAL to prove that it was lower than the initial BAL, and that *peak effect* is past.

                                          If its on the way up... then forget it.... you're not getting discharged.

                                          And before anyone points out: "But you're wasting time and resources!" I'd like to point out that a lot of us: "Would bankrupt the system if it kept us from being named in a lawsuit."
                                           

                                          la gringa

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                                            We're trying something similar at my shop, and its failing miserably. Its some scheme designed to "punch the clock" at the earliest possible moment.. and it results in multiple transfers of care, lots of information lost in-between each step, and longer stays in the ED on the whole.

                                            Metrics are like bikinis.... they're fun to look at, but they never show you what you're REALLY trying hard to see.

                                            totally agree on all accounts. unfortunately, this system is adored by my group as a whole - i guess b/c it gives the admin folks "numbers" that they like... though they love to talk about LOS, and i think it adversely affects some pts' LOS (depending on who is "out front").

                                            seems to work best at getting the lowest acuity aka not even urgent pts out the door quickly.

                                            also hate doing damage control aka "service recovery" when the doc out front is um, not so good at patient satisfaction. i guess i'm a bit of a control freak - but one with no major complaints or lawsuits in 7.5 yrs of EM (including residency) and consistently high pt satisfaction #'s and few bouncebacks...
                                             

                                            RustedFox

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                                              totally agree on all accounts. unfortunately, this system is adored by my group as a whole - i guess b/c it gives the admin folks "numbers" that they like... though they love to talk about LOS, and i think it adversely affects some pts' LOS (depending on who is "out front").

                                              seems to work best at getting the lowest acuity aka not even urgent pts out the door quickly.

                                              also hate doing damage control aka "service recovery" when the doc out front is um, not so good at patient satisfaction. i guess i'm a bit of a control freak - but one with no major complaints or lawsuits in 7.5 yrs of EM (including residency) and consistently high pt satisfaction #'s and few bouncebacks...

                                              Yuuup. Being a "control freak" is a good thing.
                                               

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                                                My patients can't do number 3 at baseline. As far as number 5, no one would leave... ever. "Hey Doc, sounds like I need to stay. Can I get another meal tray?"

                                                I could see it making for a nice looking chart, but if something happens to the patient you're still getting sued, and I would think it kills your LOS metrics.

                                                Sent from my Galaxy Nexus using Tapatalk 2


                                                Patient's cant do number 3 at baseline ? Admit them. :)

                                                Kills my LOS metrics ? Naah, I document it at the end of the shift.

                                                If something happens to the patient, its a LOT tougher to sue. Maybe not worth the effort. That's my goal; I want the attorney to look over the chart and say - "Nahhhh. Pass."
                                                 

                                                Arcan57

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                                                  Patient's cant do number 3 at baseline ? Admit them. :)

                                                  Kills my LOS metrics ? Naah, I document it at the end of the shift.

                                                  If something happens to the patient, its a LOT tougher to sue. Maybe not worth the effort. That's my goal; I want the attorney to look over the chart and say - "Nahhhh. Pass."

                                                  I think you'll be successful at that goal, it just seems like overkill in my practice environment. With our malpractice standard set pretty high, I feel that protecting my patient from reasonably foreseeable injury is important. I don't feel that keeping a patient for hours after they're clinically sober or spending money for an additional ETOH test helps the patient. Additionally, the room that the pt is tying up is usually needed by someone in the waiting room. Now if I lived in PA I'd probably practice differently.
                                                   

                                                  tkim

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                                                    I gotta admit: I was not clear in my initial post. Thanks, Tkim. You pointed out a glaring inconsistency (in all sincerity).

                                                    I document the *current* BAL to prove that it was lower than the initial BAL, and that *peak effect* is past.

                                                    If its on the way up... then forget it.... you're not getting discharged.

                                                    And before anyone points out: "But you're wasting time and resources!" I'd like to point out that a lot of us: "Would bankrupt the system if it kept us from being named in a lawsuit."

                                                    I see documenting any subsequent non-zero serum etoh just prior to discharge rather than not testing and calling them 'clinically sober' a risk.

                                                    You can explain what 'clinically sober' is, but you cannot make non-clinicians understand that you sent someone home with an alcohol level home - especially without a friend or ride. All they will take away from this is hat you discharged someone home with an alcohol level just before discharge.
                                                     

                                                    docB

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                                                      not to mention the endless "room 4 doesn't have a riiiide". i understand if it's a chronic misuser of the ED, but if it's a guy w/ angioedema and he doesn't get benadryl, HE ISN'T GETTING TREATED PROPERLY FOR HIS PROBLEM! we are rated for "control of pain" yet nurses constantly try to circumvent this.

                                                      question: do ya'll allow pts to go home in a cab after getting iv narcs, ativan, phenergan, benadryl if they pass the equivalent of a clinical sobriety test? in residency we could do that, and at my first gig (2 hospitals), but i can't where i am now.

                                                      That's a real catch 22. It shows the through the looking glass absurdities we are routinely faced with these days.

                                                      Treat their pain to their satisfaction with whatever narcotics they want but if you do you can't let them leave for four hours and you have to keep your LOS under 2 hours. Go!

                                                      As for Rusted's protocol I see where it has benefits but I could never do it in my environment. I have too many drunks and too many of them get shaky if you let them hang out. I can see where that would work in another population. I think the way you manage drunks, druggies and psychs is one of the most region dependent things in EM.
                                                       
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                                                      5. Your message is mostly quotes or spoilers.
                                                      6. Your reply has occurred very quickly after a previous reply and likely does not add anything to the thread.
                                                      7. This thread is locked.