... a meeting, a promise, a baby, and a locums....
The trauma center staffed by EMGA has done well, and hospital volumes have increased as expected - although throughput house wide, utilization of resources, and reimbursement has taken a significant hit due to the patient population that has been brought in. The ED has undergone a complete renovation and expansion, adding approximately 10 new beds combined with 4 major trauma rooms, which are primarily run by the trauma surgeons. As the trauma program has grown, the trauma surgeons have begun to voice their complaints about they patients being held in the ED, and the ED leadership has been involved in throughput initiatives to help alleviate the stack up of patients in the department. Despite the addition of 10 rooms, the additional volume has put a strain on the hospital's staffing capabilities, and a front door triage process has been tweaked to include a screening room for providers to examine patients and place them in the waiting room while they wait for inpatient beds. A whole house surge policy was considered, but due to limited physical space, and the delay of trauma patients who are increasing in house length of stay, there is no immediate solution to create beds without stepping on the cardiology and orthopedic floors for extra space. This was not taken well by those specialists, who already felt threatened by the hospital's focus on less lucrative trauma care, and they have begun to be selective on the patients that they evaluate in the ED. The orthopedists don't feel that they are getting their end of the bargain - they had expected a joint center to be opened - and feel that the majority of their call time is being spent on long bone fractures and trauma-related call. They are threatening to pull out of call, and one of the orthopedists is considering leaving altogether. The hospital CEO is being boxed into a corner due to volume he does not want, and shifting payor mix, and is becoming increasingly concerned with his anticipated shift to bundled payments and core measure withholding from CMS, which is now a major funder of his hospital. Seeing no alternative, the CEO agreed to subsidize orthopedic call coverage for trauma patients, and the orthopedists were pacified. This added to their budget loss, and would require justification to the board.
And then, a phone conversation took place one night in the Emergency Department. One of the ED providers evaluated a walk-in patient who had an impacted and comminuted proximal humerus fracture with a concomitant scapula fracture. He was initially not forthcoming with his history due to the number of beers that he drank, but it eventually became understood that he was ejected from a vehicle driven by a friend of his. They did not call the police but instead brought him to the ED. The ED physician called the orthopedist on call for evaluation of the shoulder, who demanded that the patient be evaluated by the trauma surgeon due to the mechanism of the injury. The ED physician had already performed a thorough trauma evaluation, including Pan Scan, and felt comfortable clearing the patient for orthopedic management. The trauma surgeon was notified but stated on the phone to the ED doctor that the workup was appropriate and did not need trauma evaluation. The Orthopedist refused to see the patient until Trauma took over care - stating that if they get involved, at least he could get some reimbursement because the patient was uninsured. The administrator on call was notified, and happened to be the CEO, and while he could see both sides of the clinical situation, did not want to disrupt the orthopedic relationship any further, and asked the ED physician to contact the trauma surgeon again to help the orthopedist. The ED physician reiterated that the trauma surgeon had already declined to see the patient, and the CEO offered to call the trauma surgeon himself, which he did.
Three weeks later, the ED medical director was called to meet with the CEO. Meetings like this were not unusual, especially since the CEO had many pokers in the fire and regular feedback from the ED was needed. This meeting, however had a much different tone than previous meetings. After the recent hospital Board meeting, it was determined that more providers were needed in the ED to support the trauma surgeons, and despite a previous interdepartmental agreement between ED and trauma, ED physicians would need to share management decision-making for all patients with traumatic mechanisms. Using the recent example with orthopedics, the CEO felt that patients could more readily be downgraded as non-trauma, reducing the amount of call pay the hospital would need to give to the orthopedists if they were cleared by trauma prior to being consulted. They would be required to see patients as part of their EMTALA call, and only serious trauma would cost him his call pay. The ED medical director was asked to meet with the Trauma chair and hammer out a process within the month.
An emergency meeting was held with the partners at EMGA that night. EMGA was already facing a reduction in revenue due to their anticipated construction blackout, which occurred, passed, and as expected was replaced with higher volumes of lower-paying patients. This payor mix shift, however, proved to be more than they could handle, as patients that would have been placed in rooms and evaluated quickly were held in the waiting room without space for providers to examine them. The group had considered actually reducing coverage to compensate for the loss of volume, but were now facing an administrative request to add coverage, AND see patients less likely to reimburse them. Their reserve funds had been slowly depleted, and the news did not hit well. The group looked at their volume distribution, identified several hours of the day where they could justify added coverage, and identified their lowest threshold for margin. the EMGA board agreed unanimously to add 4 hours of coverage daily during peak volume hours, and agreed that providers would keep themselves available during shifts to assist with trauma patients. They agreed to present this model to the chairman of trauma surgery for consideration. They anticipated that they would have 3 years of reserve funds in place to continue with their bonus pay, and felt that any more than 4 hours of daily coverage increase would put them in the red. Economically, they had reduced their practice margin to 4%. They were not comfortable with the loss of their cushion, but were left with little choice, and little leverage with trauma surgery. They were also left without any leverage with the hospital.
The next week, the two chairs met, and the EMGA proposal was not well received. The Trauma surgeons felt that the hospital was trying to undercut their service line, and felt threatened that the ED group was trying to take over their turf. They were able to understand the economics of the orthopedic call, but did not see how changing trauma and ED responsibility was the only answer. The Trauma chief was relieved that the ED team did not want a change, and, instead of demanding more coverage from the ED group, felt that bringing the call issue and trauma coverage issues to the medical staff would be a much better solution. Despite the CEO's request to find a solution for more coverage, both chairman felt that an alternative solution was a better option. The ED medical director met with the CEO to discuss the outcome of their meeting, and to prepare him for possible medical staff discussion of the issue. The CEO was less than pleased, and accused the ED medical director of working against him. He was concerned that discussion at the MEC (Medical Executive Committee) would open the discussion of pay for call to all specialties. Despite the meeting, the CEO instructed the ED medical director to add another physician shift to the schedule, and planned to meet with the trauma chairman separately. The ED medical director reassured that EMGA was on the CEO's side, and pledged to help in any way they could.
Another EMGA meeting was called, and the group recognized that there was no choice in the matter. They knew the CEO, knew the change in the marketplace and pressures of the change, and felt this was a necessary request from the hospital, despite being comfortable with the volume they were already seeing. The group was currently seeing 1.9 patients per hour per provider, and adding one more shift daily would reduce this to 1.5-1.6 patients per hour. While they considered the reduction in productivity to represent a temporary break until volumes improved, they were reminded that their increased coverage would likely be taken over by increased time spent with trauma patients. They had no choice and added the coverage. At the end of the meeting, one of the partners revealed to the group that she was pregnant again and expected to deliver in 5 months. While the group cheered for her, the next question raised was how coverage was going to provided while adding another physician. She then revealed that she was hoping to move to part time status, and felt that the group should recruit for a second full time physician. At the end of the meeting, EMGA had identified that they needed to hire two new doctors, and take a massive reduction in profit margin.
One week later, the hospital MEC met and the Chair of Trauma Surgery brought up the issue of orthopedic call. He mentioned in his discussion that both he and the ED chairman felt that expanded coverage was not needed, and that the entire situation could be alleviated if the pay for call issue was resolved with orthopedics. The CEO looked with disdain at the ED chairman, who interrupted the trauma chairman to inform the MEC that the group has already planned to add coverage despite the call situation and wished to be left out of call discussions due to conflict of interest. The CEO's worst fears were confirmed and the discussion devolved into additional specialties requesting pay for call. At the end of the meeting, the CEO pulled the ED chairman aside and accused him of colluding with the trauma chief a second time, and demanded additional ED staff be added to the next month's schedule.
EMGA met for a third time that month, and decided that they would collectively each work 2-3 shifts more per month to cover the schedule until a replacement was found. They had a solution and had everything mapped out. The only problem was that they had 5 months to recruit, hire, credential, and start 2 new physicians before they each had to work 19-20 shifts per month to maintain coverage. Vacations were cancelled, and the budget was reviewed to hire a recruiter. It was estimated that recruiter fees were going to be 15% of the contracted salary of each new hire. They also considered hiring a locums physician to fill slots on short notice. With their partnership rate dipping below the $300/hour mark, they felt that a short-term solution would be to hire a locum tenens for the same amount ($300/hr cost with $50 to locums firm and $250 to doctor). This could also lead to them saving long-term recruitment fees and possibly even recruiting the locums to full time partner status. They felt that their partnership rate could be preserved, and would still be attractive to the locums, as it would be more than their rate, and they would essentially come out even. All they needed was more volume and non-trauma payer mix to begin to gain traction. The group approved funding for either option by one vote.
The next day, the ED group president met with the hospital CEO to discuss their options. During that meeting, the CEO expressed his frustration with the orthopedic call situation, the trauma expansion, the payor mix, and, what he perceived to be his new problem - the ED chairman - who did not seem to be playing on the same team as he was. There was a very good discussion between both parties and the EMGA president was able to articulate the amount of work and planning the group had done to accommodate the CEO's requests. He was able to convince the CEO that the chairman was acting in good faith. Then, he presented his options to the CEO for adding coverage. He explained the group's economic situation, the changes that they made internally, and gave the CEO the option to recruit long term, and consider the addition of locums physicians in the short term. The CEO was amenable to the plan, but did not want to give anyone the perception that a less-than-qualified physician was going to be staffed in the ED. The decision was framed as part of the recruiting process, and the CEO liked the prospect of hiring a locums to work as a possible audition to a full time position in the medical staff. The group was given approval and engaged a locums company. The CEO agreed to fast track credentialing through the committee.
Two weeks later a locums was interviewed and started to work on the new schedule. He was not very well accepted by a few members of the partnership, who were leery of an outsider working in their shop. The Locums had been around several locations in the country previously and was a good provider. He made one wrong call to the orthopedist on call to arrange outpatient follow-up and the CEO was notified that there was a new provider in the ED who didn't appear to know what he was doing. The Orthopedist was not used to receiving phone calls for routine outpatient referrals, and felt that the new ED doctor needed to be reviewed and replaced. The group president was notified, the ED chairman was contacted by the chief of surgery, and the CEO became concerned that the group was not going to be able to maintain their end of the bargain. While eating lunch in the physician lounge three days later, the pregnant ED partner was overheard by the CEO talking to another physician about her new baby bump.
One month later, the EMGA president was given a 90 day notice of contract termination by the CEO and signed by the hospital board.
No economic numbers to really report in this post - EMGA is done, and the real saga will begin - who will take their place, and how will they do it? Stay tuned...
