Houston HCA staffing fiasco

[houstonerdoc]

Any thoughts on the HCA takeover in Houston by Emcare (replacing GHEP)?

I can only speak to my hospital (which will remain nameless), but it's quite the mess. I think Emcare largely underestimated the number of docs that would switch to their company, and now we are constantly having problems filling shifts. The pay is significantly better, yeah, but I'm slowly beginning to wonder if it's worth getting called ten times a day to help fill open shifts. I look at the calendar and cringe when I see just one doc scheduled.

The worst part is the horrible timing. I can't see them getting full time docs in here any time soon. It could be months/years before this gets straightened out. One solution they've found is to fill empty doc shifts with midlevels.

Was curious if any other Houston HCA docs were around to commiserate...

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[EM_Rebuilder]

I have lots of friends down there and have heard the same thing; that its a fiasco and a cash cow. Its a good time to be an EM doctor in Houston right now. I hear the residents are banking with moonlighting shifts...

EMCare has the ability to fix things and I am certain they figured it would be a fiasco for several years. There are about 30 residents a year that graduate from the Houston area, plus the draw of Corpus and other programs. EMCare will start ponying some fat sign on bonuses and get the newbies in the saddle for a 3 year commitment... Houston is growing and people want to move there; there will be growing pains, but I bet it works well in the end. EMCare did not get where they are by making poor decisions...

 

[la gringa]

weird, an HCA hospital in these parts replaced a local group w/ either EmCare or TH and it was a disaster... lasted less than a year, and replaced them w/ another local group.

 

[Arcan57]

It's a disaster at the moment, but EmCare has partnered with HCA and getting a foothold in the Houston market is apparently worth hemorrhaging cash in the short term. Houston is relatively underpenetrated by CMGs (TH has the Memorial-Hermann system as the other major CMG) and it's a growing city with a relatively recession proof economic base and a favorable medicolegal climate. The HCA hospitals have a nasty rep in Houston (I have no personal experience with working with them) so that's been making local recruiting difficult even with $400/hr offers.

 

[UnderwaterDoc]

It's a disaster at the moment, but EmCare has partnered with HCA and getting a foothold in the Houston market is apparently worth hemorrhaging cash in the short term. Houston is relatively underpenetrated by CMGs (TH has the Memorial-Hermann system as the other major CMG) and it's a growing city with a relatively recession proof economic base and a favorable medicolegal climate. The HCA hospitals have a nasty rep in Houston (I have no personal experience with working with them) so that's been making local recruiting difficult even with $400/hr offers.

$400/hr?!?

Dammit I wish I lived in Texas.

 

[RustedFox]

It's a disaster at the moment, but EmCare has partnered with HCA and getting a foothold in the Houston market is apparently worth hemorrhaging cash in the short term. Houston is relatively underpenetrated by CMGs (TH has the Memorial-Hermann system as the other major CMG) and it's a growing city with a relatively recession proof economic base and a favorable medicolegal climate. The HCA hospitals have a nasty rep in Houston (I have no personal experience with working with them) so that's been making local recruiting difficult even with $400/hr offers.

There's an HCA shop or two in my neck of the south where they can't get people to work even with hourlies in the 300-400 range. I spoke with one of the docs there recently that agreed to work *a* shift at one of them. He said - "yeah, its not worth it. I'll never make that mistake again."

 

[southerndoc]

weird, an HCA hospital in these parts replaced a local group w/ either EmCare or TH and it was a disaster... lasted less than a year, and replaced them w/ another local group.

EmCare seems to be getting a lot of HCA contracts. In at least one case that I am familiar, they took the ED without a subsidy at the same time they got the hospitalist contract.

 

[fuegofrio17]

.

 

[Arcan57]

EmCare seems to be getting a lot of HCA contracts. In at least one case that I am familiar, they took the ED without a subsidy at the same time they got the hospitalist contract.

I had heard that HCA and EmCare had partnered up (maybe as the start of an ACO?) but couldn't find any press releases during a quick Google search. The new EmCare Hospital Medicine CEO having worked as the COO for HCA's Hospital Medicine division is the closest thing I could find.

 

[joeDO2]

There's an HCA shop or two in my neck of the south where they can't get people to work even with hourlies in the 300-400 range. I spoke with one of the docs there recently that agreed to work *a* shift at one of them. He said - "yeah, its not worth it. I'll never make that mistake again."

I understand that certain jobs are harder than others but from a medical student perspective when you talk about 400/hr, its hard to imagine how these places could possibly be that bad. I mean for the amount I'd probably be willing to take shifts doing hard labor in Siberia.

 

[RustedFox]

I understand that certain jobs are harder than others but from a medical student perspective when you talk about 400/hr, its hard to imagine how these places could possibly be that bad. I mean for the amount I'd probably be willing to take shifts doing hard labor in Siberia.

Seems like a lot, yes. - The reason that its so poisonous (from my understanding) is that what minimal staff is actually present is completely incompetent, unavailable or unwilling to do anything, and the volume/acuity is high.

 

[Apollyon]

I understand that certain jobs are harder than others but from a medical student perspective when you talk about 400/hr, its hard to imagine how these places could possibly be that bad. I mean for the amount I'd probably be willing to take shifts doing hard labor in Siberia.

I can relate to the idea you are stating. I was talking a few years ago with a guy about a REALLY remote, REALLY tough job that was paying about $550/hr - which made sense once you got the details, and I mentioned what Danny Trejo said (he played "Machete", and you'd know him if you saw him):

[on being promoted from a $50/day extra to a $350/day boxing coach] How bad do you want this kid beat up?

[after being told an actor he was supposed to hit might hit back] For $350 a day, give him a bat. I used to get beat up for free.


I was saying, for $550/hr, I'd let you beat me with a rubber hose.

As long as my physical safety and my license (or getting arrested) are not at risk, hell, how bad can it be? I went to military college, and I lived in the Caribbean (out of the sunshine and tourists). For the **** with which I put up for $100/hr at other **** jobs, hell, quadruple it, and I can take it.

 

[RustedFox]

I can relate to the idea you are stating. I was talking a few years ago with a guy about a REALLY remote, REALLY tough job that was paying about $550/hr - which made sense once you got the details, and I mentioned what Danny Trejo said (he played "Machete", and you'd know him if you saw him):

[on being promoted from a $50/day extra to a $350/day boxing coach] How bad do you want this kid beat up?

[after being told an actor he was supposed to hit might hit back] For $350 a day, give him a bat. I used to get beat up for free.


I was saying, for $550/hr, I'd let you beat me with a rubber hose.

As long as my physical safety and my license (or getting arrested) are not at risk, hell, how bad can it be? I went to military college, and I lived in the Caribbean (out of the sunshine and tourists). For the **** with which I put up for $100/hr at other **** jobs, hell, quadruple it, and I can take it.

Funny that you said this. Things at my present gig have presently taken a serious turn for the dissatisfying. We're getting all the **** that other gigs have, but the 'corporate oversight' and level of control are also getting much more oppressive. There are so many other jobs in town that 'now' have the same level of ****, yet lack the oversight, that I'm seriously thinking about making a move for greener pastures.

 

[Arcan57]

I understand that certain jobs are harder than others but from a medical student perspective when you talk about 400/hr, its hard to imagine how these places could possibly be that bad. I mean for the amount I'd probably be willing to take shifts doing hard labor in Siberia.

So following up on Apollyon's Trejo example, if the difference in pay ($15k vs. $105k for 300 work days per year) is between feeding your family or being out on the street then everybody jumps at the money. For most of us, the difference between $250/hr (rough approx. of going Houston rate) and $400/hr amounts to luxury perfusion. Is what we can buy with the extra $150/hr an hour worth the perceived difference in pain between our current gig and the new place? Hard to say, but maybe. Then start factoring in that most shops are understaffed and docs are already working more at their primary gig then they want to be. So any significant number of moonlighting shifts are going to be at the expense of your current job, and so risk starts becoming an issue. Is it worth chasing the money to work at a place that may be unsustainably awful and giving up a place that pays well and you (presumably) tolerate? Factoring that in, the answer for a lot of docs is no.

Change some factors (better reputation of HCA hospitals, it being closer to July when a bunch of new docs become available, being in a market with a glut of EPs who are underutilized at their main gig, lower average pay in the market) and the calculus changes. EmCare would have to dedicate someone just to politely explain that their schedule is already full to all the docs calling and asking for shifts.

 

[Arcan57]

Funny that you said this. Things at my present gig have presently taken a serious turn for the dissatisfying. We're getting all the **** that other gigs have, but the 'corporate oversight' and level of control are also getting much more oppressive. There are so many other jobs in town that 'now' have the same level of ****, yet lack the oversight, that I'm seriously thinking about making a move for greener pastures.

Reducing pain is a good thing. Reducing pain at the expense of being unwilling to adapt to the foreseen future is less so. If you can tolerate the increased oversight and choose not to, jump to a place were you'll enjoy working. If you can't tolerate it, moving to a place that's behind the times is going to be the start of your exit out of clinical EM.

The future of EM is going to be metrics, and that's going to become supercharged when the new EM metrics get factored into value based purchasing (which may be the best oxymoron a government/medicine collaboration has ever produced). In 5 years, we'll look back at the Press-Ganey, LWBS, and door-to-doc metrics and marvel at how un-regulated we were.

Bonus fun fact: It's widely expected to be voted on in October that EPs will no longer be able to write admission orders under CMS rules. Those of you in a position to do so would be advised to start talking with C-suite about ways to implement this at your shop since in a lot of places it's going to be like dropping a bomb (especially with the new decision to admit to floor metric).

 

[docB]

EmCare and HCA are working together in some markets but not all. In Vegas HCA just went with a local group rather than EmCare.

Bonus fun fact: It's widely expected to be voted on in October that EPs will no longer be able to write admission orders under CMS rules. Those of you in a position to do so would be advised to start talking with C-suite about ways to implement this at your shop since in a lot of places it's going to be like dropping a bomb (especially with the new decision to admit to floor metric).

My first reaction to this is "Great!" I've been wanting out of the order writing business for a decade. Is there a down side for us? Fortunately I have a function in my EMR CPOE called "decision for admit" which stops my clock but doesn't require an actual admit order. Hopefully this will insulate me from long lags on getting orders.

 

[Janders]

My first reaction to this is "Great!" I've been wanting out of the order writing business for a decade. Is there a down side for us?

Yeah, I deal with all metrics constantly, and most cause headaches. But every once in a while one pops up that HELPS us. I'm not saying I'm a fan of most quality markers... I think most of them are poorly applied and create more harm, or at least more confusion/chaos, than good. However, I do enjoy it when occasionally the "pressure" is directed at the actual responsibility party, instead of ME.

Random example: In the stroke quality markers there is a measure stating there must be an attending read of the non-con CT head within 45 minutes, in the written record. This DOES help ensure even small hospitals have mechanisms to perform stat head CTs and get a written report rapidly. Annoying for somebody? yes. Helpful to me, and seemingly reasonable in a global sense? yes.

 

[deleted109597]

My first reaction to this is "Great!" I've been wanting out of the order writing business for a decade. Is there a down side for us? Fortunately I have a function in my EMR CPOE called "decision for admit" which stops my clock but doesn't require an actual admit order. Hopefully this will insulate me from long lags on getting orders.

You'd think, but many hospitals will be behind, and still expect us to do it (or lie and say it's a verbal order, as if we should take verbal orders from other physicians just for CPOE).
Also, the "decision to admit" button is going to be abused, and they'll likely just take it away. I click it every time I intubate/start BiPAP/EGDT/etc, and sometimes it's hours before I can convince someone to come down and admit the patient. The other services are in for a rude awakening with the amount of hospital oversight.

Hospitalists are getting their first tastes of core measure issues, and lots of places are starting exclusive hospitalist contracts due to failure of the "local guys".

 

[Arcan57]

You'd think, but many hospitals will be behind, and still expect us to do it (or lie and say it's a verbal order, as if we should take verbal orders from other physicians just for CPOE).
Also, the "decision to admit" button is going to be abused, and they'll likely just take it away. I click it every time I intubate/start BiPAP/EGDT/etc, and sometimes it's hours before I can convince someone to come down and admit the patient. The other services are in for a rude awakening with the amount of hospital oversight.

Hospitalists are getting their first tastes of core measure issues, and lots of places are starting exclusive hospitalist contracts due to failure of the "local guys".

One of the interpretations is that it's ok if the hospitalist dictates their orders to the EP. I imagine at least some hospitals will put measures in place to ensure that this interpretion is actually happening. It will suck in a profound way to work at these hospitals. Talk to admin to make certain this doesn't happen.

 

[EM_Rebuilder]

One of the interpretations is that it's ok if the hospitalist dictates their orders to the EP. I imagine at least some hospitals will put measures in place to ensure that this interpretion is actually happening. It will suck in a profound way to work at these hospitals. Talk to admin to make certain this doesn't happen.

I like our setup; we largely deal with residents so they come see the patient and 'do their thing'..

However, we admit IM patients mainly to private folks; when they agree with admission, we give the phone to a nurse who takes down the orders and puts them in the computer as a phone order. We refuse to be data entry clerks for private docs and you should to...

 

[pinipig523]

So what happened to all the GHEP docs? Was this unplanned?

 

[fuegofrio17]

GHEP chose to end their contract and relationship with HCA. They strategically decided that they were making much more money with their freestanding ERs than they were staffing hospital-based ERs. Thus they made the decision to divert resources away from staffing and toward the growth and expansion of their freestanding ERs.

 

[had2piknowEM]

So what happened to all the GHEP docs? Was this unplanned?

I have a few friends with GHEP. To answer your question, the majority were "let go" as GHEP had ~100 docs, but it only takes a small portion of that number to staff their free-standing EDs. Some joined other Houston groups, some stayed on with Emcare (who is paying a ridiculous amount of money right now), and "a few" docs (those who had been with the company for a while and didn't mind working majority free-standings) were able to stay on with GHEP. It's truly been an interesting development, especially after hearing from docs in all three situations.

It definitely adds to the already dubious reputation that GHEP has in the area regarding their business practices.

 

[fuegofrio17]

$400/hr?!?

Dammit I wish I lived in Texas.

One other point--$400/h is only offered as a last resort when they're desperate and can't find staffing. The regular rate is $225/h for part-time employees. So the unfortunate docs that give availability to the scheduler ahead of time are making about $175/h less than those that fill in at the last minute.

You also have to make the personal decision of how much you value your license and your future ability to provide for your family. When half the nursing staff has quit, the other half are new nursing grads and traveling nurses, and you pick up a chest pain chart that shows an EKG with a STEMI and the patient has been sitting in the lobby for 4+ hours, is it really worth it? Do you really want your name written on that chart?

 

[Arcan57]

GHEP chose to end their contract and relationship with HCA. They strategically decided that they were making much more money with their freestanding ERs than they were staffing hospital-based ERs. Thus they made the decision to divert resources away from staffing and toward the growth and expansion of their freestanding ERs.

That is easily the most positive spin possible on the situation.

 

[UnderwaterDoc]

One other point--$400/h is only offered as a last resort when they're desperate and can't find staffing. The regular rate is $225/h for part-time employees. So the unfortunate docs that give availability to the scheduler ahead of time are making about $175/h less than those that fill in at the last minute.

You also have to make the personal decision of how much you value your license and your future ability to provide for your family. When half the nursing staff has quit, the other half are new nursing grads and traveling nurses, and you pick up a chest pain chart that shows an EKG with a STEMI and the patient has been sitting in the lobby for 4+ hours, is it really worth it? Do you really want your name written on that chart?

You make a good point, I guess if I was in a situation like that I would be spending a lot of time documenting to cover my butt. It would definitely not be a long term plan. Great for clearing out some loan burden though.

 

[EM Junkie]

That is easily the most positive spin possible on the situation.

I also thought the same.

 

[fuegofrio17]

My intent wasn't to defend GHEP. Their corporate structure, allocation of profits, and treatment of emergency physicians is another discussion entirely. The point, I was trying to make (perhaps poorly) was that the profitability of the present freestanding ER model is extremely attractive. We are having akin to a dot.com era in Texas where individuals who exploit the present opportunities are becoming richly rewarded. As in the dot.com era, eventually the bubble bursts, but presently many entrepreneurial physicians are reaping the benefits of the current insurance reimbursement structure.

 

[houstonerdoc]

To clarify a bit on the GHEP situation:

GHEP ended the HCA contract in hopes that they could restructure it. They were losing money and basically told HCA that they needed to be paid more. When HCA went with EmCare, it was quite surprising (at least to all the docs I know). Many people were shocked and depressed. Most thought HCA would restructure with GHEP. This could all have been a facade, but it's what was communicated to me.

If GHEP was losing money with the HCA contract, I have no idea how EmCare is doing it. We are getting paid much more under EmCare, at least for the time being.

But uh, yeah. If anyone wants to move down to Houston and work in HCA facilities, I'd appreciate it! I'd like to cut back on my 16-19 10s a month and see my family more frequently!

 

[sazerac]

$400/hr?!?

Dammit I wish I lived in Texas.

If you worked a dozen shifts a month, you could have all four years of Texas med school tuition (18K/yr) paid off in a couple months. 🙂